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Grabitz P, Saksone L, Schorr SG, Schwietering J, Bittlinger M, Kimmelman J. Research encouraging off-label use of quetiapine: A systematic meta-epidemiological analysis. Clin Trials 2024; 21:418-429. [PMID: 38284364 DOI: 10.1177/17407745231225470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2024]
Abstract
BACKGROUND Researchers often conduct small studies on testing a drug's efficacy in off-label indications. If positive results from these exploratory studies are not followed up by larger, randomized, double-blinded trials, physicians cannot be sure of a drug's clinical value. This may lead to off-label prescriptions of ineffective treatments. We aim to describe the way clinical studies fostered off-label prescription of the antipsychotic drug quetiapine (Seroquel). METHODS In this systematic meta-epidemiological analysis, we searched EMBASE, MEDLINE, Cochrane CENTRAL and PsycINFO databases and included clinical studies testing quetiapine for unapproved indications between May 1995 and May 2022. We then assessed the frequency with which publications providing low-level evidence suggesting efficacy of quetiapine for off-label indications was not followed up by large, randomized and double-blinded trials within 5 years. RESULTS In total, 176 published studies were identified that reported potential efficacy of quetiapine in at least 26 indications. Between 2000 and 2007, publication of exploratory studies suggesting promise for off-label indications rapidly outpaced publication of confirmatory trials. In the 24 indications with a minimum of 5 years of follow-up from the first positive exploratory study, 19 (79%) were not followed up with large confirmatory trials within 5 years. At least nine clinical practice guidelines recommend the use of quetiapine for seven off-label indications in which published confirmatory evidence is lacking. CONCLUSION Many small, post-approval studies suggested the promise of quetiapine for numerous off-label indications. These findings generally went unconfirmed in large, blinded, randomized trials years after first being published. The imbalance of exploratory and confirmatory studies likely encourages ineffective off-label treatment.
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Affiliation(s)
- Peter Grabitz
- QUEST Center for Responsible Research, Berlin Institute of Health, Charité- Universitätsmedizin Berlin, Berlin, Germany
| | - Lana Saksone
- QUEST Center for Responsible Research, Berlin Institute of Health, Charité- Universitätsmedizin Berlin, Berlin, Germany
| | - Susanne Gabriele Schorr
- QUEST Center for Responsible Research, Berlin Institute of Health, Charité- Universitätsmedizin Berlin, Berlin, Germany
| | - Johannes Schwietering
- QUEST Center for Responsible Research, Berlin Institute of Health, Charité- Universitätsmedizin Berlin, Berlin, Germany
| | - Merlin Bittlinger
- Department of Equity, Ethics and Policy and Studies of Translation, Ethics and Medicine (STREAM), Biomedical Ethics Unit, McGill University, Montréal, QC, Canada
| | - Jonathan Kimmelman
- Department of Equity, Ethics and Policy and Studies of Translation, Ethics and Medicine (STREAM), Biomedical Ethics Unit, McGill University, Montréal, QC, Canada
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2
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Masi G, Carucci S, Muratori P, Balia C, Sesso G, Milone A. Contemporary diagnosis and treatment of conduct disorder in youth. Expert Rev Neurother 2023; 23:1277-1296. [PMID: 37853718 DOI: 10.1080/14737175.2023.2271169] [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] [Accepted: 10/04/2023] [Indexed: 10/20/2023]
Abstract
INTRODUCTION Conduct disorder (CD) is characterized by repetitive and persistent antisocial behaviors, being among the most frequently reported reasons of referral in youth. CD is a highly heterogeneous disorder, with possible specifiers defined according to age at onset, Limited Prosocial Emotions (LPE) otherwise known as Callous-Unemotional (CU) traits, Emotional Dysregulation (ED), and patterns of comorbidity, each with its own specific developmental trajectories. AREAS COVERED The authors review the evidence from published literature on the clinical presentations, diagnostic procedures, psychotherapeutic and psychoeducational approaches, and pharmacological interventions from RCT and naturalistic studies in youth. Evidence from studies including youths with LPE/CU traits, ED and aggression are also reviewed, as response moderators. EXPERT OPINION Due to its clinical heterogeneity, relevant subtypes of CD should be carefully characterized to gain reliable information on prognosis and treatments. Thus, disentangling this broad category in subtypes is crucial as a first step in diagnosis. Psychosocial interventions are the first option, possibly improving LPE/CU traits and ED, especially if implemented early during development. Instead, limited information, based on low-quality studies, supports pharmacological options. Second-generation antipsychotics, mood stabilizers, and stimulants are first-line medications, according to different target symptoms, such as aggression and emotional reactivity. Developmental pathways including ADHD suggest a specific role of psychostimulants.
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Affiliation(s)
- Gabriele Masi
- Department of Child and Adolescent Psychiatry and Psychopharmacology, IRCCS Stella Maris Foundation, Pisa, Italy
| | - Sara Carucci
- Department of Biomedical Science, Section of Neuroscience & Clinical Pharmacology, University of Cagliari, Cagliari, Italy
- Child & Adolescent Neuropsychiatric Unit, "A. Cao" Paediatric Hospital-ARNAS "G. Brotzu" Hospital Trust, Department of Paediatrics, Cagliari, Italy
| | - Pietro Muratori
- Department of Child and Adolescent Psychiatry and Psychopharmacology, IRCCS Stella Maris Foundation, Pisa, Italy
| | - Carla Balia
- Department of Biomedical Science, Section of Neuroscience & Clinical Pharmacology, University of Cagliari, Cagliari, Italy
- Child & Adolescent Neuropsychiatric Unit, "A. Cao" Paediatric Hospital-ARNAS "G. Brotzu" Hospital Trust, Department of Paediatrics, Cagliari, Italy
| | - Gianluca Sesso
- Department of Child and Adolescent Psychiatry and Psychopharmacology, IRCCS Stella Maris Foundation, Pisa, Italy
- Social and Affective Neuroscience Group, Molecular Mind Lab, IMT School for Advanced Studies Lucca, Lucca, Italy
| | - Annarita Milone
- Department of Child and Adolescent Psychiatry and Psychopharmacology, IRCCS Stella Maris Foundation, Pisa, Italy
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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: 4] [Impact Index Per Article: 4.0] [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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Stepanova E, Langfus JA, Youngstrom EA, Evans SC, Stoddard J, Young AS, Van Eck K, Findling RL. Finding a Needed Diagnostic Home for Children with Impulsive Aggression. Clin Child Fam Psychol Rev 2023; 26:259-271. [PMID: 36609931 DOI: 10.1007/s10567-022-00422-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/19/2022] [Indexed: 01/09/2023]
Abstract
Aggressive behavior is one of the most common reasons for referrals of youth to mental health treatment. While there are multiple publications describing different types of aggression in children, it remains challenging for clinicians to diagnose and treat aggressive youth, especially those with impulsively aggressive behaviors. The reason for this dilemma is that currently several psychiatric diagnoses include only some of the common symptoms of aggression in their criteria. However, no single diagnosis or diagnostic specifier adequately captures youth with impulsive aggression (IA). Here we review select current diagnostic categories, including behavior and mood disorders, and suggest that they do not provide an adequate description of youth with IA. We also specifically focus on the construct of IA as a distinct entity from other diagnoses and propose a set of initial, provisional diagnostic criteria based on the available evidence that describes youth with IA to use for future evaluation.
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Affiliation(s)
- Ekaterina Stepanova
- Virginia Commonwealth University, 1308 Sherwood Ave, Richmond, VA, 23220, USA.
| | - Joshua A Langfus
- University of North Carolina at Chapel Hill, 235 E Cameron Ave, CB# 3270, Chapel Hill, NC, 27514, USA
| | - Eric A Youngstrom
- University of North Carolina at Chapel Hill, 103 Westchester Pl, Chapel Hill, NC, 27514-5237, USA
| | - Spencer C Evans
- University of Miami, 5665 Ponce de Leon Blvd, Coral Gables, FL, 33146, USA
| | - Joel Stoddard
- University of Colorado Anschutz Medical Campus, Aurora, 13123 East 16Th Ave, Aurora, CO, 80045, USA
| | - Andrea S Young
- Johns Hopkins University, 1800 Orleans Street, Bloomberg 12N, Baltimore, MD, 21287, USA
| | - Kathryn Van Eck
- Johns Hopkins University, 1800 Orleans Street, Bloomberg 12N, Baltimore, MD, 21287, USA
| | - Robert L Findling
- Virginia Commonwealth University, 501 N 2Nd St 4Th Floor, PO Box 980308, Richmond, VA, 23298-0308, USA
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5
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Sesso G, Masi G. Pharmacological strategies for the management of the antisocial personality disorder. Expert Rev Clin Pharmacol 2023; 16:181-194. [PMID: 36787887 DOI: 10.1080/17512433.2023.2181159] [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: 11/21/2022] [Accepted: 02/09/2023] [Indexed: 02/16/2023]
Abstract
INTRODUCTION Antisocial personality disorder (AsPD) is a pervasive pattern of violation of others' rights, related to the concept of psychopathy. AsPD is stable over time from adolescence, with evidence of conduct disorder (CD) before 15 years. DSM-5 included a specifier 'with limited prosocial emotions' (LPE), which characterizes adolescents with higher developmental vulnerability to develop AsPD. Despite being relatively frequent with considerable societal impact, AsPD is a difficult-to-treat condition with high comorbidity rates and poor evidence for effective pharmacological interventions. AREAS COVERED We conducted a narrative review and searched PubMed up to September 2022. We included RCTs and naturalistic studies evaluating pharmacological interventions on AsPD in adults, including those with comorbid substance use disorder or psychopathic traits. Evidence in youths with CD, callous-unemotional (CU) traits and aggression were also reviewed, exploring the role of CU traits as moderators of response. EXPERT OPINION Psychosocial interventions are the first option, with possible improvement of CU traits, beyond behavioral and affective symptoms, particularly if implemented early during development. Limited information, based on low-quality studies, supports the pharmacological options. Second-generation antipsychotics, lithium, anti-epileptic drugs, and stimulants are first-line medications, according to different target symptoms. Developmental pathways including ADHD suggest a specific role of psychostimulants.
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Affiliation(s)
- Gianluca Sesso
- Social and Affective Neuroscience Group, Molecular Mind Lab, IMT School for Advanced Studies Lucca, Lucca, Italy
- Department of Child and Adolescent Psychiatry and Psychopharmacology, IRCCS Stella Maris Foundation, Pisa, Italy
| | - Gabriele Masi
- Department of Child and Adolescent Psychiatry and Psychopharmacology, IRCCS Stella Maris Foundation, Pisa, Italy
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6
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Pharmacotherapy of Disruptive Behaviors in Children with Intellectual Disabilities. Paediatr Drugs 2022; 24:465-482. [PMID: 35781194 DOI: 10.1007/s40272-022-00517-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/24/2022] [Indexed: 10/17/2022]
Abstract
Disruptive behaviors are a class of predominantly externalizing behaviors that include physical aggression, property destruction, temper outbursts, verbal aggression, and some forms of self-injurious behaviors. Externalizing behaviors are also major components of disruptive, impulse-control and conduct disorders, disruptive mood dysregulation disorder, trauma-related and stressor-related disorders, intermittent explosive disorder, personality disorders, and other neuropsychiatric and neurodevelopmental disorders. Disruptive behaviors and associated disorders are among the most frequent reasons for child behavioral health referrals and are the most common reason for referrals among children with intellectual disabilities. The focus of this paper is on the adjunctive role of integrated psychopharmacological treatment in the management of children with disruptive behaviors and co-occurring intellectual disabilities. The decision-making process for adding pharmacotherapy to a comprehensive treatment plan incorporates not only a working knowledge of basic behavioral neurobiology of disruptive behaviors but also an understanding of the strengths and weaknesses of various pharmacotherapies. Importantly, there is little evidence to support the use of psychopharmacologic agents in managing difficult behaviors in children with intellectual disabilities, but with that said, risperidone has the strongest evidence base for its use.
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7
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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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Abstract
Explosive and aggressive behavior in children can pose safety risks, disturb family functioning, and lead to significant impairments. Pharmacologic management should be based on the first-line treatment of the primary psychiatric diagnoses of the patient and initiated in combination with appropriate psychosocial interventions. Review of the literature suggests that risperidone has the most supporting evidence in the treatment of explosive behavior. Stimulants have been shown to be helpful in the treatment of explosive behavior in attention-deficit/hyperactivity disorder. Medication treatment can be associated with significant side effects and therefore the risks and benefits of medication management must be weighed carefully.
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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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Juárez-Treviño M, Esquivel AC, Isida LML, Delgado DÁG, de la O Cavazos ME, Ocañas LG, Sepúlveda RS. Clozapine in the Treatment of Aggression in Conduct Disorder in Children and Adolescents: A Randomized, Double-blind, Controlled Trial. CLINICAL PSYCHOPHARMACOLOGY AND NEUROSCIENCE 2019; 17:43-53. [PMID: 30690939 PMCID: PMC6361039 DOI: 10.9758/cpn.2019.17.1.43] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Revised: 03/22/2018] [Accepted: 03/23/2018] [Indexed: 01/06/2023]
Abstract
Objective This study was conducted to compare the efficacy of clozapine vs. risperidone in the treatment of aggression in conduct disorder in children and adolescents. Methods Twenty-four children with conduct disorder aged 6 to 16 years were randomized in a prospective, double-blind trial into two groups to receive clozapine or risperidone for 16 weeks. The Modified Overt Aggression Scale score was used as the primary outcome of the study. Secondary outcomes were Child Behavior Checklist (CBCL) externalization (CBCL-E) and internalization factors; Aggression, Hyperactivity and Delinquency subscales of CBCL-E, Child Global Assessment Scale (CGAS), Barnes Akathisia Rating Scale, and Simpson-Angus Scale. Results Both antipsychotics were similarly effective in the primary outcome and in most of the secondary ones. Clozapine was more effective in CBCL-E, the delinquency subscale and the CGAS scores than risperidone (p =0.039, 0.010, and 0.021). Two subjects from the clozapine group were excluded due to a low neutrophil count at week four. Conclusion Clozapine and risperidone are effective for short-term treatment of aggression in children and adolescents with conduct disorder. Clozapine was more effective than risperidone in conduct externalization factors, delinquency trait and global functioning in children and adolescents. Stronger efficacy of clozapine should be investigated in larger sample sizes using pharmacogenomic studies. White blood cell counts need to be monitored when prescribing clozapine.
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Affiliation(s)
- Myrthala Juárez-Treviño
- Department of Psychiatry, Hospital Universitario, Universidad Autónoma de Nuevo León, Mexico
| | | | - Lilia Marytza Leal Isida
- Department of Psychiatry, Instituto Tecnológicoy de Estudios Superiores de Monterrey ITESM, Escuela de Medicina, NL, Mexico
| | | | | | - Lourdes Garza Ocañas
- Department of Pharmacology, Hospital Universitario, Universidad Autónoma de Nuevo León, Mexico
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11
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Huang X, Zhang S, Ma Y, Yang H, He C, Tian R, Mei H, Liu L, Zhang B. Bioequivalence of two quetiapine extended release tablets in Chinese healthy volunteers under fasting and fed conditions and effects of food on pharmacokinetic profiles. DRUG DESIGN DEVELOPMENT AND THERAPY 2018; 13:255-264. [PMID: 30643391 PMCID: PMC6319427 DOI: 10.2147/dddt.s182965] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Objective The objectives of this study were to evaluate the bioequivalence of Quesero extended release (Quesero XR) tablets and Seroquel extended release (Seroquel XR) tablets under fasting and fed conditions and to determine the effect of food on the pharmacokinetic (PK) properties of Quesero XR or Seroquel XR in Chinese healthy volunteers. Methods A single-site, randomized, open-label, two-period crossover design with a 10-day washout period was conducted in 20 subjects under the fed and fasting studies. A single oral dose of 200 mg Quesero XR or Seroquel XR was given to the subjects after an overnight fast of 10 hours. Blood samples were taken at scheduled time spots from 0 hour pre dose to 36 hours post dose. Plasma concentrations of quetiapine were measured by a validated ultra-performance liquid chromatography-tandem mass spectrometry (UPLC-MS/MS) method. The PK parameters were calculated by non-compartment analysis using Phoenix WinNonlin software. Results On both conditions, no significant differences were found among the main PK parameters of the two preparations by analysis of variance (P>0.05); the Wilcoxon test of maximum peak plasma concentration (Tmax) showed no significant differences (P>0.05); the 90% confidence limit (CL) of lnCmax, lnAUC0→36, and lnAUC0→∞ fell within the acceptable range of 80%–125%. As compared with the fasting state, the Tmax was advanced and the mean maximum plasma concentration (Cmax), AUC0→36, and AUC0→∞ were also increased in the fed state; the geometric mean ratio and 90% CI of the main PK parameters fell outside the range of the CIs; analysis of variance showed significant differences in the other PK parameters except for apparent total clearance after oral administration (clearance rate; P<0.05). Conclusion The two formulations of Quesero XR and Seroquel XR are bioequivalent under both fasting and fed conditions, and food may affect the PK profiles by increasing the rate and extent of absorption of Quesero XR or Seroquel XR in Chinese healthy volunteers.
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Affiliation(s)
- Xiaomei Huang
- Department of National Drug Clinical Trial Research Center, Xiangya Boai Rehabilitation Hospital, Changsha, People's Republic of China, ;
| | - Suhua Zhang
- Department of Pharmacy, The Second Xiangya Hospital of Central South University, Changsha, People's Republic of China, .,Institute of Clinical Pharmacy, Central South University, Changsha, People's Republic of China,
| | - Yanxia Ma
- Department of National Drug Clinical Trial Research Center, Xiangya Boai Rehabilitation Hospital, Changsha, People's Republic of China, ;
| | - Heng Yang
- Department of National Drug Clinical Trial Research Center, Xiangya Boai Rehabilitation Hospital, Changsha, People's Republic of China, ;
| | - Chuan He
- Department of National Drug Clinical Trial Research Center, Xiangya Boai Rehabilitation Hospital, Changsha, People's Republic of China, ;
| | - Rufang Tian
- Department of National Drug Clinical Trial Research Center, Xiangya Boai Rehabilitation Hospital, Changsha, People's Republic of China, ;
| | - Han Mei
- Department of National Drug Clinical Trial Research Center, Xiangya Boai Rehabilitation Hospital, Changsha, People's Republic of China, ;
| | - Lipeng Liu
- Department of National Drug Clinical Trial Research Center, Xiangya Boai Rehabilitation Hospital, Changsha, People's Republic of China, ;
| | - Bikui Zhang
- Department of National Drug Clinical Trial Research Center, Xiangya Boai Rehabilitation Hospital, Changsha, People's Republic of China, ; .,Department of Pharmacy, The Second Xiangya Hospital of Central South University, Changsha, People's Republic of China, .,Institute of Clinical Pharmacy, Central South University, Changsha, People's Republic of China,
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Fortea A, Ilzarbe D, Espinosa L, Solerdelcoll M, de Castro C, Oriolo G, Sugranyes G, Baeza I. Long-Acting Injectable Atypical Antipsychotic Use in Adolescents: An Observational Study. J Child Adolesc Psychopharmacol 2018; 28:252-257. [PMID: 29381388 DOI: 10.1089/cap.2017.0096] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVES Although second generation long-acting injectable antipsychotics (SG-LAIAs) have been approved and are widely used in adults, there is limited evidence for the use of long-acting formulations in children and adolescents. Thus, we systematically describe the off-label use of SG-LAIAs in clinical practice in adolescent inpatients. METHODS All individuals admitted to our Children and Adolescent Inpatient Psychiatry Unit receiving treatment with SG-LAIAs between January 2013 and June 2016 were reviewed. A retrospective analysis of medical records was conducted. Clinical diagnoses were established using DSM-5 criteria. RESULTS Thirty individuals (53.3% female) out of a total of 1,148 admitted patients (2.6%) were identified. The mean age was 16.3 (SD = 1.3; range: 12.5-17.9).The main diagnoses were psychosis (70%) and disruptive behavior disorders (DBDs) (30%), although comorbidity was frequent (96.6%), especially drug use (55.2%, mostly cannabis). SG-LAIAs used were aripiprazole (40%), risperidone (36.7%), and paliperidone palmitate (23.3%), and the main reasons were a history of low compliance (90%) and/or poor insight (73.3%). A mean improvement of 31.7 (SD = 8.7) between admission and discharge was registered in the Children's Global Assessment Scale (CGAS); no differences were observed between different SG-LAIAs. Although they were generally well tolerated, 23.3% of patients reported mild short-term side effects, which were more frequent with risperidone than with aripiprazole (p = .014). CONCLUSIONS Our clinical experience suggests that SG-LAIAs may be a safe treatment option during adolescence in inpatients with psychotic disorders, as well as with DBD. No differences were found in CGAS improvement scores between the three SGA-LAIAs used, although patients on risperidone reported more side effects than those on aripiprazole. Further research is needed so as to evaluate safety and effectiveness of SG-LAIAs in this population.
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Affiliation(s)
- Adriana Fortea
- 1 Department of Psychiatry and Psychology, Institute of Neuroscience, Hospital Clinic de Barcelona , Barcelona, Spain
| | - Daniel Ilzarbe
- 2 Department of Child and Adolescent Psychiatry, Institute of Psychiatry, King's College of London , London, United Kingdom
| | - Laura Espinosa
- 1 Department of Psychiatry and Psychology, Institute of Neuroscience, Hospital Clinic de Barcelona , Barcelona, Spain
| | - Mireia Solerdelcoll
- 1 Department of Psychiatry and Psychology, Institute of Neuroscience, Hospital Clinic de Barcelona , Barcelona, Spain
| | - Clara de Castro
- 3 Centro de Salud Mental Infanto-Juvenil, Hospital Sant Joan de Déu , Cornellá de Llobregat, Barcelona, Spain
| | - Giovanni Oriolo
- 1 Department of Psychiatry and Psychology, Institute of Neuroscience, Hospital Clinic de Barcelona , Barcelona, Spain
| | - Gisela Sugranyes
- 4 Department of Child and Adolescent Psychiatry, Institute of Neuroscience, Hospital Clínic de Barcelona , Barcelona, Spain .,5 Institut d'Investigacions Biomèdiques Agustí Pi i Sunyer (CERCA-IDIBAPS) , Barcelona, Spain .,6 Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM) , Barcelona, Spain
| | - Inmaculada Baeza
- 4 Department of Child and Adolescent Psychiatry, Institute of Neuroscience, Hospital Clínic de Barcelona , Barcelona, Spain .,5 Institut d'Investigacions Biomèdiques Agustí Pi i Sunyer (CERCA-IDIBAPS) , Barcelona, Spain .,6 Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM) , Barcelona, Spain
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Loy JH, Merry SN, Hetrick SE, Stasiak K. Atypical antipsychotics for disruptive behaviour disorders in children and youths. Cochrane Database Syst Rev 2017; 8:CD008559. [PMID: 28791693 PMCID: PMC6483473 DOI: 10.1002/14651858.cd008559.pub3] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND This is an update of the original Cochrane Review, last published in 2012 (Loy 2012). Children and youths with disruptive behaviour disorders may present to health services, where they may be treated with atypical antipsychotics. There is increasing usage of atypical antipsychotics in the treatment of disruptive behaviour disorders. OBJECTIVES To evaluate the effect and safety of atypical antipsychotics, compared to placebo, for treating disruptive behaviour disorders in children and youths. The aim was to evaluate each drug separately rather than the class effect, on the grounds that each atypical antipsychotic has different pharmacologic binding profile (Stahl 2013) and that this is clinically more useful. SEARCH METHODS In January 2017, we searched CENTRAL, MEDLINE, Embase, five other databases and two trials registers. SELECTION CRITERIA Randomised controlled trials of atypical antipsychotics versus placebo in children and youths aged up to and including 18 years, with a diagnosis of disruptive behaviour disorders, including comorbid ADHD. The primary outcomes were aggression, conduct problems and adverse events (i.e. weight gain/changes and metabolic parameters). The secondary outcomes were general functioning, noncompliance, other adverse events, social functioning, family functioning, parent satisfaction and school functioning. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. Two review authors (JL and KS) independently collected, evaluated and extracted data. We used the GRADE approach to assess the quality of the evidence. We performed meta-analyses for each of our primary outcomes, except for metabolic parameters, due to inadequate outcome data. MAIN RESULTS We included 10 trials (spanning 2000 to 2014), involving a total of 896 children and youths aged five to 18 years. Bar two trials, all came from an outpatient setting. Eight trials assessed risperidone, one assessed quetiapine and one assessed ziprasidone. Nine trials assessed acute efficacy (over four to 10 weeks); one of which combined treatment with stimulant medication and parent training. One trial was a six-month maintenance trial assessing symptom recurrence.The quality of the evidence ranged from low to moderate. Nine studies had some degree of pharmaceutical support/funding. Primary outcomesUsing the mean difference (MD), we combined data from three studies (238 participants) in a meta-analysis of aggression, as assessed using the Aberrant Behaviour Checklist (ABC) ‒ Irritability subscale. We found that youths treated with risperidone show reduced aggression compared to youths treated with placebo (MD -6.49, 95% confidence interval (CI) -8.79 to -4.19; low-quality evidence). Using the standardised mean difference (SMD), we pooled data from two risperidone trials (190 participants), which used different scales: the Overt Aggression Scale ‒ Modified (OAS-M) Scale and the Antisocial Behaviour Scale (ABS); as the ABS had two subscales that could not be combined (reactive and proactive aggression), we performed two separate analyses. When we combined the ABS Reactive subscale and the OAS-M, the SMD was -1.30 in favour of risperidone (95% CI -2.21 to -0.40, moderate-quality evidence). When we combined the ABS Proactive subscale and OAS-M, the SMD was -1.12 (95% CI -2.30 to 0.06, moderate-quality evidence), suggesting uncertainty about the estimate of effect, as the confidence intervals overlapped the null value. In summary, there was some evidence that aggression could be reduced by risperidone. Data were lacking on other atypical antipsychotics, like quetiapine and ziprasidone, with regard to their effects on aggression.We pooled data from two risperidone trials (225 participants) in a meta-analysis of conduct problems, as assessed using the Nisonger Child Behaviour Rating Form ‒ Conduct Problem subscale (NCBRF-CP). This yielded a final mean score that was 8.61 points lower in the risperidone group compared to the placebo group (95% CI -11.49 to -5.74; moderate-quality evidence).We investigated the effect on weight by performing two meta-analyses. We wanted to distinguish between the effects of antipsychotic medication only and the combined effect with stimulants, since the latter can have a counteracting effect on weight gain due to appetite suppression. Pooling two trials with risperidone only (138 participants), we found that participants on risperidone gained 2.37 kilograms (kg) more (95% CI 0.26 to 4.49; moderate-quality evidence) than those on placebo. When we added a trial where all participants received a combination of risperidone and stimulants, we found that those on the combined treatment gained 2.14 kg more (95% CI 1.04 to 3.23; 3 studies; 305 participants; low-quality evidence) than those on placebo. Secondary outcomesOut of the 10 included trials, three examined general functioning, social functioning and parent satisfaction. No trials examined family or school functioning. Data on non-compliance/attrition rate and other adverse events were available from all 10 trials. AUTHORS' CONCLUSIONS There is some evidence that in the short term risperidone may reduce aggression and conduct problems in children and youths with disruptive behaviour disorders There is also evidence that this intervention is associated with significant weight gain.For aggression, the difference in scores of 6.49 points on the ABC ‒ Irritability subscale (range 0 to 45) may be clinically significant. It is challenging to interpret the clinical significance of the differential findings on two different ABS subscales as it may be difficult to distinguish between reactive and proactive aggression in clinical practice. For conduct problems, the difference in scores of 8.61 points on the NCBRF-CP (range 0 to 48) is likely to be clinically significant. Weight gain remains a concern.Caution is required in interpreting the results due to the limitations of current evidence and the small number of high-quality trials. There is a lack of evidence to support the use of quetiapine, ziprasidone or any other atypical antipsychotic for disruptive behaviour disorders in children and youths and no evidence for children under five years of age. It is uncertain to what degree the efficacy found in clinical trials will translate into real-life clinical practice. Given the effectiveness of parent-training interventions in the management of these disorders, and the somewhat equivocal evidence on the efficacy of medication, it is important not to use medication alone. This is consistent with current clinical guidelines.
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Affiliation(s)
- Jik H Loy
- Waikato DHBChild and Adolescent Mental Health206 Colllingwood StreetHamiltonNew Zealand
| | - Sally N Merry
- University of AucklandDepartment of Psychological MedicinePrivate Bag 92019AucklandNew Zealand1142
| | - Sarah E Hetrick
- Orygen, The National Centre of Excellence in Youth Mental Health and The Centre of Youth Mental Health, University of Melbourne35 Poplar RoadParkvilleMelbourneVictoriaAustralia3054
| | - Karolina Stasiak
- University of AucklandDepartment of Psychological MedicinePrivate Bag 92019AucklandNew Zealand1142
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Lytle S, McVoy M, Sajatovic M. Long-Acting Injectable Antipsychotics in Children and Adolescents. J Child Adolesc Psychopharmacol 2017; 27:2-9. [PMID: 28112539 DOI: 10.1089/cap.2016.0055] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE While a number of articles have reviewed the use of long-acting injectable antipsychotics (LAIs) in first-episode psychosis, there has been extremely limited focus on LAIs in children and adolescents. This review of the literature evaluated use of LAIs in children and youth under the age of 18. METHODS We conducted a comprehensive search of the PubMed, PsychINFO, CINAHL, and EMBASE databases using keywords related to LAIs, children, and psychiatric conditions, including schizophrenia, bipolar disorder, and schizoaffective disorder. Reports were included if they were in English, conducted between 1971 and 2015, and reported on use of LAIs in individuals less than the age of 18. RESULTS The search identified seven reports including one open-label trial, three case reports, and three case series. No controlled trials were found. Sample sizes ranged from 1 to 19 with a total of 36 individuals in all cases combined. Mean sample age was 12.1 ± 2.2 in the open-label trial and calculated to be 14.9 ± 1.5 in the remainder of the reports. Most patients (80.6%) were boys. Primary diagnoses included bipolar I disorder (n = 18; 50%), schizophrenia (n = 7; 19.4%), and bipolar spectrum disorders (n = 6; 16.6%). The LAIs used were risperidone long-acting injection (n = 24; 66.7%), paliperidone palmitate (n = 8; 22.2%), fluphenazine decanoate (n = 1; 2.8%), aripiprazole extended-release injectable (n = 1; 2.8%), zuclopenthixol decanoate (n = 1; 2.8%), and olanzapine extended release (n = 1; 2.8%). Most cases reported clinical improvement and the majority of individuals (n = 14; 82.4%) were reported to tolerate the medication well. The most common side effects were weight gain (mean 5.7 ± 4.1 kg in the open-label trial), tremor (n = 2; 5.6%), and oculogyric crisis (n = 2; 5.6%). CONCLUSIONS This literature review suggests that LAI use in youth with serious mental illness may improve clinical outcomes and adherence. Side effects of LAIs among youth appear are similar to oral preparations. However, there is a paucity of data despite issues with nonadherence in youth and the fact that they have much to lose and much to gain. Existing reports have substantial methodological limitations, and research is needed to guide the use of LAIs in children and adolescents.
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Affiliation(s)
- Sarah Lytle
- Department of Psychiatry, University Hospitals Cleveland Medical Center , Cleveland, Ohio
| | - Molly McVoy
- Department of Psychiatry, University Hospitals Cleveland Medical Center , Cleveland, Ohio
| | - Martha Sajatovic
- Department of Psychiatry, University Hospitals Cleveland Medical Center , Cleveland, Ohio
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15
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Balia C, Carucci S, Coghill D, Zuddas A. The pharmacological treatment of aggression in children and adolescents with conduct disorder. Do callous-unemotional traits modulate the efficacy of medication? Neurosci Biobehav Rev 2017; 91:218-238. [PMID: 28137460 DOI: 10.1016/j.neubiorev.2017.01.024] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Revised: 12/07/2016] [Accepted: 01/20/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND Children and adolescents with conduct disorder (CD) show repetitive and persistent patterns of aggressive behaviour and the more severe forms are often associated with callous-unemotional (CU) traits. OBJECTIVES To systematically review and, where data are adequate, conduct meta-analyses on the efficacy of medication on aggression in children and adolescent with CD considering the impact of CU traits. RESULTS Few studies have investigated patients with CD as primary diagnosis, and few of these have discriminated between different types of aggression or reported measures of CU traits. Methylphenidate and risperidone showed the largest effects on aggression in randomized controlled trials; other antipsychotics showed clinical efficacy on CD but this evidence is mainly revealed by open label trials. There is some low quality evidence to support a small effect of mood stabilizers and other agents. There were only two papers describing the effects of CU traits thus providing inconclusive results. CONCLUSION Considering heterogeneity of the disorder, more proof-of-concept clinical studies are needed to define effects of medication and role of CU traits.
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Affiliation(s)
- Carla Balia
- Child & Adolescent Neuropsychiatric Unit, Department of Biomedical Science, University of Cagliari & "A. Cao" Microcitemico Paediatric Hospital, Cagliari, Italy
| | - Sara Carucci
- Child & Adolescent Neuropsychiatric Unit, Department of Biomedical Science, University of Cagliari & "A. Cao" Microcitemico Paediatric Hospital, Cagliari, Italy.
| | - David Coghill
- Division of Neuroscience, University of Dundee, Dundee, UK; Departments of Paediatrics and Psychiatry, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Australia
| | - Alessandro Zuddas
- Child & Adolescent Neuropsychiatric Unit, Department of Biomedical Science, University of Cagliari & "A. Cao" Microcitemico Paediatric Hospital, Cagliari, Italy
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Therapeutic drug monitoring of second-generation antipsychotics in pediatric patients: an observational study in real-life settings. Eur J Clin Pharmacol 2015; 72:285-93. [DOI: 10.1007/s00228-015-1982-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2015] [Accepted: 11/16/2015] [Indexed: 01/10/2023]
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Efficacy and Safety of Risperidone and Quetiapine in Adolescents With Bipolar II Disorder Comorbid With Conduct Disorder. J Clin Psychopharmacol 2015; 35:587-90. [PMID: 26226481 DOI: 10.1097/jcp.0000000000000371] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Although a frequent co-occurrence between bipolar disorder (BD) and conduct disorder (CD) in youth has been frequently reported, data about pharmacological management are scarce and focused on BD type I. Second generation antipsychotics are frequently used in clinical practice, but no comparative studies are available. The aim of this exploratory study was to compare efficacy and safety of risperidone and quetiapine in a sample of adolescents presenting a BD type II comorbid with CD. Twenty-two patients diagnosed with a structured interview according to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, (male/female ratio, 12/10; mean (SD) age 15.0 (1.4) years) were randomized in 2 treatment groups (quetiapine [n = 12] vs risperidone [n = 10]), treated with flexible doses, and followed up for 12 weeks. Efficacy measures assessed manic symptoms, aggression, anxiety, depression, global clinical severity, and impairment. Safety measures included body mass index, serum prolactin, extrapyramidal adverse effects, and electrocardiogram. At the end of the study, all patients improved in all efficacy measures. Both treatments showed similar efficacy in reducing manic symptoms and aggression. Quetiapine was more effective in improving anxiety and depressive symptoms. A change in body mass index was found, and in a post hoc analysis, it was significant only in the risperidone group. Prolactin significantly increased only in the risperidone group. In BD type II, CD comorbidity, quetiapine, or risperidone monotherapy may be effective and relatively safe, although the small sample size, the limited duration of the study, and the design (lack of a blind assessments and of a placebo group) make it difficult to draw definitive conclusions.
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Teixeira EH, Jacintho A, Celeri HV, Dalgalarrondo P. Atypical antipsychotics in the treatment of pathological aggression in children and adolescents: literature review and clinical recommendations. TRENDS IN PSYCHIATRY AND PSYCHOTHERAPY 2015; 35:151-9. [PMID: 25923387 DOI: 10.1590/s2237-60892013000300002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/30/2011] [Accepted: 07/02/2012] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To review the literature about the use of atypical antipsychotics in the treatment of pathological aggression in children and adolescents. METHOD The databases MEDLINE, SciELO, and LILACS were searched for publications in Portuguese or English from 1992 to August 2011 using the following keywords: mental disease, child, adolescent, treatment, atypical antipsychotic, aggressive behavior, aggression, and violent behavior. RESULTS Sixty-seven studies of good methodological quality and clinical interest and relevance were identified. Studies including children and adolescents were relatively limited, because few atypical antipsychotics have been approved by the Food and Drug Administration (FDA). All the medications included in this review (risperidone, olanzapine, quetiapine, ziprasidone, aripiprazole and clozapine) have some effectiveness in treating aggression in children and adolescents, and choices should be based on clinical indications and side effects. CONCLUSIONS There are few studies about the effectiveness and safety of atypical antipsychotics for the pediatric population, and further randomized controlled studies with larger groups of patients and more diagnostic categories, such as severe conduct disorder and oppositional defiant disorder, should be conducted to confirm the results reported up to date and to evaluate the impact of long-term use.
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Affiliation(s)
| | - Antonio Jacintho
- Child and Adolescent Psychiatry Outpatient Unit, Hospital de Clínicas, Universidade Estadual de Campinas, Campinas, SP, Brazil
| | | | - Paulo Dalgalarrondo
- Department of Medical Psychology and Psychiatry, School of Medical Sciences, UNICAMP, Campinas, SP, Brazil
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Whitney Z, Boyda HN, Procyshyn RM, Elbe D, Black T, Eslami A, Barr AM. Therapeutic drug levels of second generation antipsychotics in youth: a systematic review. J Child Adolesc Psychopharmacol 2015; 25:234-45. [PMID: 25803501 DOI: 10.1089/cap.2014.0044] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE In children and adolescents, the prevalence rate of mental illness is claimed to be as high as 10-20%. Effective pharmacological treatments are available for use in children, adolescents, and adults; however, most of what is known about the effects of these treatments has been confirmed in clinical studies involving adults only. Second generation antipsychotic drugs (SGAs) are the most common class of antipsychotic medication used in pediatric populations, and these drugs are increasingly being used for disorders other than psychosis. Many SGAs are routinely used in pediatric care, and the vast majority of use in this population is off label. Children, adolescents, and adults differ in age, weight, height, and metabolism, which may lead to pharmacokinetic differences in how drugs ultimately affect target tissues. The aim of this review is to summarize and evaluate the literature that investigated blood plasma levels of SGAs in youth. METHODS Plasma levels were assessed in relation to their administered dose, indication, and therapeutic range (if known). Studies were limited to those evaluating oral administration only. A systematic electronic database search for peer-reviewed articles published between 2000 and 2013 was conducted. Twenty-one articles were included in the review. Additional articles for discussion were also included throughout the article. RESULTS The only SGA that may require routine therapeutic drug monitoring (TDM) in youth given the current body of research is clozapine. Highly variable results were seen in studies of aripiprazole, olanzapine, and risperidone, indicating that more research is needed on plasma levels with these drugs. Quetiapine maintained a similar profile to that found in adults, with no dosage adjustments or indications of TDM. CONCLUSION TDM may be indicated in any circumstance in which cytochrome P450 inhibitors or inducers are coprescribed. Further research is required for establishing a sounder safety profile for SGA use in the pediatric population.
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Affiliation(s)
- Zachary Whitney
- 1 Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia , Vancouver, British Columbia, Canada
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Abstract
The atypical antipsychotic quetiapine has been used in different psychotic and non-psychotic disorders in children and adolescents in randomized clinical trials, open-label studies and chart reviews. Most of these studies suggest that quetiapine may be a promising agent with a potential for use in young patients. The aim of this paper is to critically review available literature on quetiapine in the treatment of children and adolescents with a variety of psychiatric disorders, including psychotic disorders, bipolar disorders (manic and depressive episodes), conduct disorder, autism spectrum disorder, Tourette's syndrome and personality disorders. Furthermore, we report on possible neurochemical pathways involved during treatment with quetiapine, and discuss some issues that are clinically relevant in daily practice, such as titration strategies, safety and tolerability, and monitoring possible side effects. Controlled studies support the short-term efficacy for treating psychosis, mania, and aggression within certain diagnostic categories. However, although quetiapine seems well tolerated in various pediatric populations during acute and intermediate treatments, and hyper-prolactinemia and extra-pyramidal side effects are consistently low among studies, weight gain and alterations in lipid profile need to be closely monitored. Furthermore, the distal benefit/risk ratio during long-term treatment remains to be determined.
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Rettew DC, Greenblatt J, Kamon J, Neal D, Harder V, Wasserman R, Berry P, MacLean CD, Hogue N, McMains W. Antipsychotic medication prescribing in children enrolled in Medicaid. Pediatrics 2015; 135:658-65. [PMID: 25733747 DOI: 10.1542/peds.2014-2260] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/22/2015] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Although the increase in treatment of children and adolescents with antipsychotic medications has been well documented, much less is known about the factors related to the use of these agents and how closely the treatment follows best practice recommendations. METHODS Prescribers of each antipsychotic medication prescription issued for a Medicaid-insured child in Vermont aged <18 years were sent a prior authorization survey that assessed several domains including the clinical indication, other treatments, metabolic monitoring, prescriber specialty, and prescription origin. These variables were combined to categorize prescriptions as following indications approved by the US Food and Drug Administration (FDA) and best practice guidelines. RESULTS The response rate of the survey was 80%, with 677 surveys from 147 prescribers available for analysis; more than one-half of the respondents were primary care clinicians. Overall, the clinical indication for an antipsychotic prescription followed best practice guidelines 91.7% of the time, with overall best practice guidelines followed at a rate of 50.1%. An FDA indication was followed in 27.2% of cases. Psychiatrists were significantly more likely to follow best practice guidelines than nonpsychiatrists. Antipsychotic medications were typically used only after other pharmacologic and nonpharmacologic treatments were ineffective, although previous treatment with cognitive-behavioral therapy was uncommon (15.5%). Metabolic monitoring that included serial laboratory tests was reported in 57.2% of cases. CONCLUSIONS Current prescribing patterns of antipsychotic medications for children and adolescents follow best practice guidelines approximately one-half of the time, with nonadherence often related to lack of metabolic monitoring.
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Affiliation(s)
- David C Rettew
- The Vermont Center for Children, Youth, and Families, Department of Psychiatry, University of Vermont, Burlington, Vermont; Vermont Child Health Improvement Program, Department of Pediatrics, and
| | - Jeanne Greenblatt
- The Vermont Center for Children, Youth, and Families, Department of Psychiatry, University of Vermont, Burlington, Vermont; Vermont Child Health Improvement Program, Department of Pediatrics, and
| | - Jody Kamon
- Vermont Child Health Improvement Program, Department of Pediatrics, and
| | | | - Valerie Harder
- Vermont Child Health Improvement Program, Department of Pediatrics, and
| | - Richard Wasserman
- Vermont Child Health Improvement Program, Department of Pediatrics, and
| | - Patricia Berry
- Vermont Child Health Improvement Program, Department of Pediatrics, and
| | - Charles D MacLean
- Department of Medicine, University of Vermont College of Medicine, Burlington, Vermont
| | - Nancy Hogue
- Department of Vermont Health Access, Williston, Vermont; and
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Masi G, Pisano S, Pfanner C, Milone A, Manfredi A. Quetiapine monotherapy in adolescents with bipolar disorder comorbid with conduct disorder. J Child Adolesc Psychopharmacol 2013; 23:568-71. [PMID: 24138010 PMCID: PMC3804383 DOI: 10.1089/cap.2013.0063] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Bipolar Disorders (BD) are often comorbid with disruptive behaviour disorders (DBDs) (oppositional-defiant disorder or conduct disorder), with negative implications on treatment strategy and outcome. The aim of this study was to assess the efficacy of quetiapine monotherapy in adolescents with BD comorbid with conduct disorder (CD). A consecutive series of 40 adolescents (24 males and 16 females, age range 12-18 years, mean age 14.9 ± 2.0 years), diagnosed with a clinical interview (Kiddie Schedule for Affective Disorders and Schizophrenia for School-Aged Children-Present and Lifetime Version [K-SADS-PL]) according to American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, 4th ed., Text Revision (DSM-IV-TR) criteria were included. All the patients were treated with quetiapine monotherapy (mean final dose 258 ± 124 mg/day, range 100-600 mg/day). At the end-point (3 months), 22 patients (55.0%) were responders (Clinical Global Impressions-Improvement [CGI-I] score of 1 or 2 and CGI-Severity [CGI-S] ≤ 3 and improvement of at least 30% Children's Global Assessment Scale [C-GAS] during 3 consecutive months). Both CGI-S and C-GAS significantly improved (p<0.0001). Nine out of the 16 patients with suicidality (56.3%) had a reduction in this severe symptom during the follow-up. Nonresponders were more frequently males, and more frequently had an attention-deficit/hyperactivity disorder (ADHD) comorbidity. Eight patients (20.0%) experienced moderate to severe sedation and eight (20.0%) experienced increased appetite and weight gain. In these severely impaired adolescents, quetiapine monotherapy was well tolerated and effective in>50% of the patients.
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Affiliation(s)
- Gabriele Masi
- Scientific Institute Stella Maris for Child Neurology and Psychiatry, Calambrone, Pisa, Italy
| | - Simone Pisano
- Department of Mental and Physical Health and Preventative Medicine, Division of Child and Adolescent Psychiatry, Second University of Naples, Naples, Italy
| | - Chiara Pfanner
- Scientific Institute Stella Maris for Child Neurology and Psychiatry, Calambrone, Pisa, Italy
| | - Annarita Milone
- Scientific Institute Stella Maris for Child Neurology and Psychiatry, Calambrone, Pisa, Italy
| | - Azzurra Manfredi
- Scientific Institute Stella Maris for Child Neurology and Psychiatry, Calambrone, Pisa, Italy
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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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Affiliation(s)
- W David Lohr
- niversity of Louisville School of Medicine, Louisville, KY 40202, USA.
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25
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Loy JH, Merry SN, Hetrick SE, Stasiak K. Atypical antipsychotics for disruptive behaviour disorders in children and youths. Cochrane Database Syst Rev 2012:CD008559. [PMID: 22972123 DOI: 10.1002/14651858.cd008559.pub2] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Disruptive behaviour disorders include conduct disorder, oppositional defiant disorder and disruptive behaviour not otherwise specified. Attention deficit hyperactivity disorder (ADHD) is frequently associated with disruptive behaviour disorders. The difficulties associated with disruptive behaviour disorders are demonstrated through aggression and severe behavioural problems. These often result in presentation to psychiatric services and may be treated with medications such as atypical antipsychotics. There is increasing evidence of a significant rise in the use of atypical antipsychotics for treating disruptive behaviour disorders in child and adolescent populations. OBJECTIVES To evaluate the effect and safety of atypical antipsychotics, compared to placebo, for treating disruptive behaviour disorders in children and youths. SEARCH METHODS We searched the following databases in August 2011: CENTRAL (2011, Issue 3), MEDLINE (1948 to August Week 1), EMBASE (1980 to 2011 Week 32), PsycINFO (1806 to August Week 2 2011), CINAHL (1937 to current), ClinicalTrials.gov (searched 15 August 2011), Australian New Zealand Clinical Trials Registry (ANZCTR) (searched 15 August 2011), CenterWatch (searched 15 August 2011) and ICTRP (searched 15 August 2011). SELECTION CRITERIA We included randomised controlled trials with children and youths up to and including the age of 18, in any setting, with a diagnosis of a disruptive behaviour disorder. We included trials where participants had a comorbid diagnosis of attention deficit hyperactivity disorder, major depression or an anxiety disorder. DATA COLLECTION AND ANALYSIS Two review authors independently selected the studies and disagreements were resolved by discussion. Two review authors extracted data independently. One review author entered data into Review Manager software and another checked it. We contacted trial authors for information about adverse effects and to provide missing data. MAIN RESULTS We included eight randomised controlled trials, spanning 2000 to 2008. Seven assessed risperidone and one assessed quetiapine. Three of the studies were multicentre. Seven trials assessed acute efficacy and one assessed time to symptom recurrence over a six-month maintenance period.We performed meta-analyses for the primary outcomes of aggression, conduct problems and weight changes but these were limited by the available data as different trials reported either mean change scores (average difference) or final/post-intervention raw scores and used different outcome measures. We also evaluated each individual trial's treatment effect size where possible, using Hedges' g.For aggression, we conducted two meta-analyses. The first included three trials (combined n = 238) using mean difference (MD) on the Aberrant Behaviour Checklist (ABC) Irritability subscale. Results yielded a final mean score with treatment that was 6.49 points lower than the post-intervention mean score with placebo (95% confidence interval (CI) -8.79 to -4.19). The second meta-analysis on aggression included two trials (combined n = 57) that employed two different outcome measures (Overt Aggression Scale (modified) (OAS-M) and OAS, respectively) and thus we used a standardised mean difference. Results yielded an effect estimate of -0.18 (95% CI -0.70 to 0.34), which was statistically non-significant.We also performed two meta-analyses for conduct problems. The first included two trials (combined n = 225), both of which employed the Nisonger Child Behaviour Rating Form - Conduct Problem subscale (NCBRF-CP). The results yielded a final mean score with treatment that was 8.61 points lower than that with placebo (95% CI -11.49 to -5.74). The second meta-analysis on conduct problems included two trials (combined n = 36), which used the Conners' Parent Rating Scale - Conduct Problem subscale (CPRS-CP). Results yielded a mean score with treatment of 12.67 lower than with placebo (95% CI -37.45 to 12.11), which was a statistically non-significant result.With respect to the side effect of weight gain, a meta-analysis of two studies (combined n = 138) showed that participants on risperidone gained on average 2.37 kilograms more than those in the placebo group over the treatment period (MD 2.37; 95% CI 0.26 to 4.49).For individual trials, there was a range of effect sizes (ranging from small to large) for risperidone reducing aggression and conduct problems. The precision of the estimate of the effect size varied between trials. AUTHORS' CONCLUSIONS There is some limited evidence of efficacy of risperidone reducing aggression and conduct problems in children aged 5 to 18 with disruptive behaviour disorders in the short term.For aggression, the difference in scores of 6.49 points on the ABC Irritability subscale (range 0 to 45) may be clinically significant. For conduct problems, the difference in scores of 8.61 points on the NCBRF-CP (range 0 to 48) is likely to be clinically significant.Caution is required due to the limitations of the evidence and the small number of relevant high-quality studies. The findings from the one study assessing impact in the longer term suggest that the effects are maintained to some extent (small effect size) for up to six months. Inadequately powered studies produced non-significant results. The evidence is restricted by heterogeneity of the population (including below average and borderline IQ), and methodological issues in some studies, such as use of enriched designs and risk of selection bias. No study addressed the issue of pre-existing/concurrent psychosocial interventions, and comorbid stimulant medication and its dosage was only partially addressed. There is currently no evidence to support the use of quetiapine for disruptive behaviour disorders in children and adolescents.It is uncertain to what degree the efficacy found in clinical trials will translate into real life clinical practice. Participants in the studies were recruited from clinical services but those who agree to take part in the clinical trials are a subset of the overall population presenting for care. There are no research data for children under five years of age. Further high-quality research is required with large samples of clinically representative youths and long-term follow-up to replicate current findings.
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Affiliation(s)
- Jik H Loy
- Child and Adolescent Mental Health, Health Waikato, Hamilton, New Zealand.
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Matson JL, Belva BC, Hattier MA, Matson ML. Scaling methods to measure psychopathology in persons with intellectual disabilities. RESEARCH IN DEVELOPMENTAL DISABILITIES 2012; 33:549-562. [PMID: 22119704 DOI: 10.1016/j.ridd.2011.10.023] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/15/2011] [Accepted: 09/15/2011] [Indexed: 05/31/2023]
Abstract
Psychopathology prior to the last four decades was generally viewed as a set of problems and disorders that did not occur in persons with intellectual disabilities (ID). That notion now seems very antiquated. In no small part, a revolutionary development of scales worldwide has occurred for the assessment of emotional problems in persons with ID. The first standardized test to emerge was the Psychopathology Instrument for Mentally Retarded Adults (PIMRA) in 1984. Since that time, an impressive number of measures of general psychopathology have emerged for adults and children as well as for persons across the full range of levels of ID. The purpose of this review was to provide a description of available measures, to review papers published on these measures, and to discuss emerging trends in test development. The trends in this body of information for enhancing differential diagnosis of psychopathology in persons with ID are discussed.
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Affiliation(s)
- Johnny L Matson
- Department of Psychology, Louisiana State University, Baton Rouge, LA 70803, USA.
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Intelligenzminderung. PSYCHIATRIE UND PSYCHOTHERAPIE DES KINDES- UND JUGENDALTERS 2012. [PMCID: PMC7123948 DOI: 10.1007/978-3-642-19846-5_27] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Schwachsinn Der Gebrauch des Terminus »Schwachsinn« ist wegen seines globalen und wenig präzisen Charakters und durch seine historisch und umgangssprachlich bedingte sozial diskriminierende Tönung inzwischen in der wissenschaftlichen Literatur zu Recht weitgehend aufgegeben worden. In der Rechtsprechung speziell in der Forensik ist Schwachsinn als eine schuldausschließende bzw. schuldminderende juristische Kategorie ein nach wie vor gebräuchlicher Begriff.
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Zai CC, Ehtesham S, Choi E, Nowrouzi B, de Luca V, Stankovich L, Davidge K, Freeman N, King N, Kennedy JL, Beitchman JH. Dopaminergic system genes in childhood aggression: possible role for DRD2. World J Biol Psychiatry 2012; 13:65-74. [PMID: 21247255 DOI: 10.3109/15622975.2010.543431] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
UNLABELLED Excessive or deficient levels of extracellular dopamine have been hypothesized to contribute to a broad spectrum of mood, motor, and thought abnormalities, and dopaminergic system genes have been implicated in aggressive behaviour from animal and human studies. OBJECTIVE. We examined selected members of the dopaminergic system genes for association with child aggression. METHOD We analyzed polymorphisms in the dopamine transporter DAT1/SLC6A3, dopamine receptor DRD2, and DRD4 genes in our sample of pervasive childhood aggression consisting of 144 cases paired with 144 healthy controls, matched for sex and ethnicity. RESULTS Aggressive children were significantly more likely to have the at least one copy of the G allele for the DRD2 A-241G polymorphism (genotypic P=0.02; allelic P=0.01). The DRD2 rs1079598 CC genotype was overrepresented in aggressive children compared to controls (genotype P=0.04). The DRD2 TaqIA T allele (P=0.01) and the TT genotype (P=0.01) were also significantly overrepresented in aggressive children. CONCLUSIONS Our preliminary results suggest that three polymorphisms in DRD2 are associated with childhood aggression. Future studies are required to replicate the current results and to further explore the relationship between the dopamine system and aggressive behaviour in children.
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Affiliation(s)
- Clement C Zai
- Neurogenetics Section, Centre for Addiction and Mental Health, Toronto, Canada
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29
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Hässler F, Reis O. Pharmacotherapy of disruptive behavior in mentally retarded subjects: A review of the current literature. ACTA ACUST UNITED AC 2011; 16:265-72. [PMID: 20981765 DOI: 10.1002/ddrr.119] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The review presented here describes the state of the art of pharmacological treatment of aggression in subjects with mental retardation (MR) summing up results for both, children and adults. In general, psychopharmacological treatment of disruptive behavior in individuals with MR is similar to the treatment in subjects without MR. Compared to individuals without MR medication should "start lower and go slower." For children and adults results were similar but were obtained by somewhat different medications. There is evidence for the conventional antipsychotic zuclopenthixol having positive effects on disruptive behavior. Most studies described the atypical antipsychotic risperidone to control severe self-injurious behavior and other behavior problems in a variety of diagnoses. Anticonvulsants, antidepressants, and anxiolytic medications are reported as effective as well for the treatment of individuals with disruptive behavior. Aggression-related behavior often gets treated with stimulants or with stimulants combined with atypical neuroleptics.
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Affiliation(s)
- Frank Hässler
- Department of Child and Adolescent Neuropsychiatry, University of Rostock, Rostock, Germany.
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30
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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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31
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Quetiapine and norquetiapine in plasma and cerebrospinal fluid of schizophrenic patients treated with quetiapine: correlations to clinical outcome and HVA, 5-HIAA, and MHPG in CSF. J Clin Psychopharmacol 2010; 30:496-503. [PMID: 20814316 DOI: 10.1097/jcp.0b013e3181f2288e] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
This study investigated concentrations of quetiapine and norquetiapine in plasma and cerebrospinal fluid (CSF) in 22 schizophrenic patients after 4-week treatment with quetiapine (600 mg/d), which was preceded by a 3-week washout period. Blood and CSF samples were obtained on days 1 and 28, and CSF levels of homovanillic acid (HVA), 5-hydroxyindoleacetic acid (5-HIAA), and 3-methoxy-4-hydroxyphenylglycol (MHPG) concentrations were measured at baseline and after 4 weeks of quetiapine, allowing calculations of differences in HVA (ΔHVA), 5-HIAA (Δ5-HIAA), and MHPG (ΔMHPG) concentrations. Patients were assessed clinically, using the Positive and Negative Syndrome Scale (PANSS) and Clinical Global Impression Scale at baseline and then at weekly intervals. Plasma levels of quetiapine and norquetiapine were 1110 ± 608 and 444 ± 226 ng/mL, and the corresponding CSF levels were 29 ± 18 and 5 ± 2 ng/mL, respectively. After the treatment, the levels of HVA, 5-HIAA, and MHPG were increased by 33%, 35%, and 33%, respectively (P < 0.001). A negative correlation was found between the decrease in PANSS positive subscale scores and CSF ΔHVA (r(rho) = -0.690, P < 0.01), and the decrease in PANSS negative subscale scores both with CSF Δ5-HIAA (r(rho) = -0.619, P = 0.02) and ΔMHPG (r(rho) = -0.484, P = 0.038). Because, unfortunately, schizophrenic patients experience relapses even with the best available treatments, monitoring of CSF drug and metabolite levels might prove to be useful in tailoring individually adjusted treatments.
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Pfeifer JC, Kowatch RA, DelBello MP. Pharmacotherapy of bipolar disorder in children and adolescents: recent progress. CNS Drugs 2010; 24:575-93. [PMID: 20441242 DOI: 10.2165/11533110-000000000-00000] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Child and adolescent bipolar disorder (BPD) is a serious psychiatric disorder that often causes significant impairment in functioning. Pharmacological intervention is the cornerstone of treatment for bipolar youth, although psychotherapeutic interventions may be beneficial as adjunctive treatment. Medications used for the treatment of BPD in adults are still commonly used for bipolar children and adolescents. With the recent US FDA indication of risperidone, aripiprazole, quetiapine and olanzapine for the treatment of bipolar youth, the atypical antipsychotics are rapidly becoming a first-line treatment option. However, these agents are associated with adverse effects such as increased appetite, weight gain and type II diabetes mellitus. Although several evidence-based medications are now available for the treatment of BPD in younger populations, additional studies to evaluate the short- and long-term efficacy and potential for adverse events of these and other medications are needed.
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Affiliation(s)
- Jonathan C Pfeifer
- Division of Child Psychiatry, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
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Pharmacokinetics and Therapeutic Drug Monitoring of Psychotropic Drugs in Pediatrics. Ther Drug Monit 2009; 31:283-318. [DOI: 10.1097/ftd.0b013e31819f3328] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
The growing literature shows the pervasiveness and importance of comorbidity in youth with bipolar disorder (BPD). For instance, up to 90% of youth with BPD have been described to manifest comorbidity with attention-deficit hyperactivity disorder. Multiple anxiety, substance use, and disruptive behavior disorders are the other most commonly reported comorbidities with BPD. Moreover, important recent data highlight the importance of obsessive-compulsive and pervasive developmental illness in the context of BPD. Data suggest that not only special developmental relationships are operant in the context of comorbidity but also that the presence of comorbid disorders with BPD results in a more severe clinical condition. Moreover, the presence of comorbidity has therapeutic implications for the treatment response for both BPD and the associated comorbid disorder. Future longitudinal studies to address the relationship and the impact of comorbid disorders on course and therapeutic response over time are required in youth with BPD.
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Affiliation(s)
- Gagan Joshi
- Scientific Director, Pervasive Developmental Disorders Program, Clinical and Research Programs in Pediatric Psychopharmacology, Massachusetts General Hospital; Instructor in Psychiatry, Harvard Medical School
| | - Timothy Wilens
- Director, Substance Abuse Services, Pediatric Psychopharmacology Clinic, Massachusetts General Hospital; Associate Professor of Psychiatry, Harvard Medical School
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36
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Abstract
Understanding pediatric psychopharmacology often is an important part of the practice of a general psychiatrist, as a substantial number of children and adolescents are affected by a major psychiatric illness. A general psychiatrist should consider some key issues before he or she begins prescribing psychotropic medications to children and adolescents. Some agents that are effective in adults may not be effective in youths, and similarly, medications that are well tolerated in adults may be associated with accentuated or additional risks when prescribed to young people. This article is an effort to summarize the recent advances in medication therapy of the pediatric population and bring the general psychiatrist up to date on the evidence-based psychopharmacologic treatment of children and adolescents.
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Zarcone J, Napolitano D, Valdovinos M. Measurement of problem behaviour during medication evaluations. JOURNAL OF INTELLECTUAL DISABILITY RESEARCH : JIDR 2008; 52:1015-1028. [PMID: 18717764 DOI: 10.1111/j.1365-2788.2008.01109.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
BACKGROUND The focus of this review is on methods that are currently being used to evaluate the behavioural effects of medication for individuals with intellectual disabilities. First we describe what has been identified as the ideal criteria for conducting clinical trials and how these criteria may be adapted to do less controlled evaluations. The central theme is a review of the biological measures (e.g. labs, drug levels), behavioural rating scales and direct observation measures that are often used to evaluate medication effects. Issues related to how the side effects of medication can affect behaviour will also be discussed. CONCLUSION The importance of encouraging communication and collaboration across all systems of care and the use of socially valid measures are discussed.
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Affiliation(s)
- J Zarcone
- University of Rochester Medical Center, Rochester, New York 14642, USA.
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38
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Ulloa RE, Nicolini H, Avila M, Fernández-Guasti A. Randomized controlled pilot study of quetiapine in the treatment of adolescent conduct disorder. J Child Adolesc Psychopharmacol 2008; 18:140-56. [PMID: 17343556 DOI: 10.1089/cap.2006.0007] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE The aim of this study was to examine whether quetiapine is superior to placebo in the treatment of adolescents with conduct disorder. METHODS This was a 7-week, randomized, double-blind, placebo-controlled pilot study with two parallel arms. Nine youths were randomly assigned to receive quetiapine, and 10 youths were randomly assigned to receive placebo. Patients were assessed weekly throughout the trial. Quetiapine was dosed twice daily, and medications could be titrated flexibly through the end of study week 5. The dose was fixed for the final 2 weeks of the study. The primary outcome measures were the clinician-assessed Clinical Global Impressions-Severity (CGI-S) and-Improvement (CGI-I) scales. Secondary outcome measures included parent-assessed quality of life, the overt aggression scale (OAS), and the conduct problems subscale of the Conners' Parent Rating Scale (CPRS-CP). RESULTS The final mean dose of quetiapine was 294 +/- 78 mg/day (range 200-600 mg/day). Quetiapine was superior to placebo on all clinician-assessed measures and on the parent-assessed quality of life rating scale. No differences were found on the parent-completed OAS and CPRS-CP. Quetiapine was well tolerated. One patient randomized to quetiapine developed akathisia, requiring medication discontinuation. No other extrapyramidal side effects occurred in patients receiving active drug. CONCLUSIONS This methodologically controlled pilot study provides data that quetiapine may have efficacy in the treatment of adolescents with conduct disorder. Because of the preliminary nature of the study, further research with larger samples is needed to confirm these findings.
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Affiliation(s)
- Rosa-Elena Ulloa
- Hospital Psiquiátrico Infantil Dr. Juan N. Navarro, Mexico City, Mexico.
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39
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Abstract
Children with psychiatric illness may display pathologic aggression (PA) that is destructive, severe, chronic, and unresponsive to psychosocial and psychopharmacological treatment of their underlying condition(s) and psychosocial interventions specifically targeting PA. For this subset of children with PA, pharmacotherapy may be an appropriate treatment option to optimize their functioning. This article reviews pharmacological treatment studies for PA in children and the safety and efficacy of risperidone, olanzapine, lithium, divalproex sodium, methylphenidate, and typical antipsychotics in this patient population. While safety needs to be emphasized when prescribing medication for these patients, serious health and safety risks are also raised when PA is not effectively treated. Future research is needed to evaluate whether the long-term risks associated with the pharmacological treatment of PA outweigh the potential benefits to the child.
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Affiliation(s)
- Drew H Barzman
- Division of Child and Adolescent Psychiatry, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio 45229-3039, USA.
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40
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Winter HR, Earley WR, Hamer-Maansson JE, Davis PC, Smith MA. Steady-state pharmacokinetic, safety, and tolerability profiles of quetiapine, norquetiapine, and other quetiapine metabolites in pediatric and adult patients with psychotic disorders. J Child Adolesc Psychopharmacol 2008; 18:81-98. [PMID: 18294091 DOI: 10.1089/cap.2007.0084] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE The aim of this study was to investigate the steady-state pharmacokinetic, safety, and tolerability profiles of immediate-release quetiapine administered by similar dose-escalation regimens in pediatric and adult populations with psychotic or mood disorders. METHODS Pediatric patients aged 10-17 years were titrated to a quetiapine dose of 200 mg twice daily (b.i.d. on days 5-7, 400 mg b.i.d. on days 11-12, with a final 400-mg dose on day 13. In a separate trial, adult patients aged 18-45 years were titrated to a quetiapine dose of 200 mg b.i.d. on days 4-6, 400 mg b.i.d. on days 10-11, with a final 400-mg dose on day 12. Concentrations of quetiapine and three metabolites (quetiapine sulfoxide, 7-hydroxy quetiapine, and norquetiapine) were quantified in plasma and urine. Adverse events, vital signs, 12-lead electrocardiogram (ECG), and clinical laboratory tests were evaluated throughout the studies. RESULTS In both pediatric and adult populations, plasma concentrations of quetiapine and norquetiapine increased proportionately as the dose was escalated from 200 mg b.i.d. to 400 mg b.i.d. There were no age-related differences in the dose-normalized quetiapine plasma concentration-time curve (AUC(SS)) and maximum plasma concentration (C(SS,max)). Quetiapine was rapidly absorbed after 200-mg and 400-mg doses in pediatric patients [median t(max) (time to maximum plasma concentration) 1.5 hours, both doses] and adult patients (median t(max) 1.0 hour and 1.2 hours, respectively). The mean quetiapine t(1/2) (terminal elimination half-life) was approximately 6 hours for pediatric and 5 hours for adult patients. Norquetiapine displayed a similar median t(max) and a longer t(1/2) compared with quetiapine. Quetiapine was well tolerated, with no serious adverse events and no unexpected events reported. CONCLUSION Pediatric and adult populations demonstrated similar pharmacokinetic, safety, and tolerability profiles for quetiapine administered by dose escalation. The predictability in quetiapine concentration profiles for children aged 10 years to adults suggests that no dosage adjustment may be required when treating patients of these ages.
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Affiliation(s)
- Helen R Winter
- Clinical Pharmacokinetics, Clinical Pharmacology, Astra-Zeneca Pharmaceuticals LP, 1800 Concord Pike, Wilmington, DE 19850, USA
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41
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Pfeifer JC, Kowatch RA, DelBello MP. The use of antipsychotics in children and adolescents with bipolar disorders. Expert Opin Pharmacother 2007; 8:2673-87. [DOI: 10.1517/14656566.8.16.2673] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Jonathan C Pfeifer
- The University of Cincinnati Medical Center, Cincinnati Children's Hospital Medical Center, Department of Psychiatry, MSB 7261, PO Box 670559, Cincinnati, Ohio 45267-0559, USA ;
| | - Robert A Kowatch
- The University of Cincinnati Medical Center, Cincinnati Children's Hospital Medical Center, Department of Psychiatry, MSB 7261, PO Box 670559, Cincinnati, Ohio 45267-0559, USA ;
| | - Melissa P DelBello
- The University of Cincinnati Medical Center, Cincinnati Children's Hospital Medical Center, Department of Psychiatry, MSB 7261, PO Box 670559, Cincinnati, Ohio 45267-0559, USA ;
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Abstract
PURPOSE OF REVIEW Inadequate handling of an uncooperative child preoperatively results in postoperative behavior problems. Premedication enables a calm induction and helps to decrease postoperative problems. Several premedicants will be covered in this review. RECENT FINDINGS Questions raised about the effects of oral midazolam use in children for premedication are now finding answers. New agents (dexmedetomidine and atypical antipsychotic agents) can be alternatives in premedication, especially in severely uncooperative children. The current literature highlights the missing information about the rather older premedicants. SUMMARY The benefits and disadvantages of new and older drugs should be weighed against each other, and decisions should be made according to the requirements of surgery, ward conditions and the severity of psychologic, developmental or mental disease. Further studies for the evaluation of the anxiolytic, sedative and antipsychotic drugs are still required.
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Affiliation(s)
- Pervin Bozkurt
- Department of Anesthesiology and Reanimation, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey.
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Findling RL, Newcorn JH, Malone RP, Waheed A, Prince JB, Kratochvil CJ. Pharmacotherapy of aggression in a 9-year-old with ADHD. J Am Acad Child Adolesc Psychiatry 2007; 46:653-658. [PMID: 17450057 DOI: 10.1097/chi.0b013e3180335b4a] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- Robert L Findling
- Dr. Findling is with the Departments of Psychiatry and Pediatrics, University Hospitals of Cleveland/Case Western Reserve University; Dr. Newcorn is with the Department of Psychiatry, Mount Sinai Medical Center, New York; Drs. Malone and Waheed are with the Department of Psychiatry, Drexel University College of Medicine, Philadelphia; Dr. Prince is with the Department of Psychiatry, Harvard Medical School, Boston; and Dr. Kratochvil is with the Department of Psychiatry, University of Nebraska Medical Center, Omaha
| | - Jeffrey H Newcorn
- Dr. Findling is with the Departments of Psychiatry and Pediatrics, University Hospitals of Cleveland/Case Western Reserve University; Dr. Newcorn is with the Department of Psychiatry, Mount Sinai Medical Center, New York; Drs. Malone and Waheed are with the Department of Psychiatry, Drexel University College of Medicine, Philadelphia; Dr. Prince is with the Department of Psychiatry, Harvard Medical School, Boston; and Dr. Kratochvil is with the Department of Psychiatry, University of Nebraska Medical Center, Omaha
| | - Richard P Malone
- Dr. Findling is with the Departments of Psychiatry and Pediatrics, University Hospitals of Cleveland/Case Western Reserve University; Dr. Newcorn is with the Department of Psychiatry, Mount Sinai Medical Center, New York; Drs. Malone and Waheed are with the Department of Psychiatry, Drexel University College of Medicine, Philadelphia; Dr. Prince is with the Department of Psychiatry, Harvard Medical School, Boston; and Dr. Kratochvil is with the Department of Psychiatry, University of Nebraska Medical Center, Omaha
| | - Ayesha Waheed
- Dr. Findling is with the Departments of Psychiatry and Pediatrics, University Hospitals of Cleveland/Case Western Reserve University; Dr. Newcorn is with the Department of Psychiatry, Mount Sinai Medical Center, New York; Drs. Malone and Waheed are with the Department of Psychiatry, Drexel University College of Medicine, Philadelphia; Dr. Prince is with the Department of Psychiatry, Harvard Medical School, Boston; and Dr. Kratochvil is with the Department of Psychiatry, University of Nebraska Medical Center, Omaha
| | - Jefferson B Prince
- Dr. Findling is with the Departments of Psychiatry and Pediatrics, University Hospitals of Cleveland/Case Western Reserve University; Dr. Newcorn is with the Department of Psychiatry, Mount Sinai Medical Center, New York; Drs. Malone and Waheed are with the Department of Psychiatry, Drexel University College of Medicine, Philadelphia; Dr. Prince is with the Department of Psychiatry, Harvard Medical School, Boston; and Dr. Kratochvil is with the Department of Psychiatry, University of Nebraska Medical Center, Omaha
| | - Christopher J Kratochvil
- Dr. Findling is with the Departments of Psychiatry and Pediatrics, University Hospitals of Cleveland/Case Western Reserve University; Dr. Newcorn is with the Department of Psychiatry, Mount Sinai Medical Center, New York; Drs. Malone and Waheed are with the Department of Psychiatry, Drexel University College of Medicine, Philadelphia; Dr. Prince is with the Department of Psychiatry, Harvard Medical School, Boston; and Dr. Kratochvil is with the Department of Psychiatry, University of Nebraska Medical Center, Omaha.
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Findling RL, Reed MD, O'Riordan MA, Demeter CA, Stansbrey RJ, McNamara NK. A 26-week open-label study of quetiapine in children with conduct disorder. J Child Adolesc Psychopharmacol 2007; 17:1-9. [PMID: 17343549 DOI: 10.1089/cap.2006.0027] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE The aim of this study was to describe the long-term safety and effectiveness of quetiapine in conduct disorder (CD). METHODS This was an 18-week outpatient follow-up study of an acute trial that enrolled aggressive children ages 6-12 years with a primary diagnosis of CD. To be enrolled into this study, subjects had to have successfully completed participation in the initial 8-week, open-label, outpatient quetiapine trial. Psychometric measures included the Rating of Aggression Against People and/or Property Scale (RAAPP), the Nisonger Child Behavior Rating Form (NCBRF), the Conners' Parent Rating Scale (CPRS-48), the Clinical Global Impressions Scale of Severity (CGI-S), and the Children's Global Assessment Scale. RESULTS Nine males with a mean age of 8.9 (SD = 1.2) years were treated. The median quetiapine dose at end of study was 150 mg/day (range 75-350). Mean psychometric scores did not change substantively from baseline. No patients experienced extrapyramidal side effects. Three subjects discontinued due to study nonadherence. No patients discontinued treatment due to an adverse event. CONCLUSIONS These preliminary data suggest that quetiapine might be a generally safe and effective maintenance treatment for aggressive children with CD who initially respond to an acute therapeutic trial of quetiapine. More research is needed to confirm or refute these initial findings.
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Affiliation(s)
- Robert L Findling
- Department of Psychiatry, University Hospitals of Cleveland/Case Western Reserve University, Cleveland, Ohio 44106-5080, USA.
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Current awareness: Pharmacoepidemiology and drug safety. Pharmacoepidemiol Drug Saf 2007. [DOI: 10.1002/pds.1358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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