Severe extrapyramidal symptoms in a 3-year-old boy after accidental ingestion of the new antipsychotic drug aripiprazole

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

INTRODUCTION

Increased prescribing of antipsychotics and availability of new antipsychotics has resulted in increased exposures in children. Current data on aripiprazole, brexpiprazole, and cariprazine are limited.

METHODS

This was a retrospective database study utilizing the National Poison Data System from 2015 through 2021. We included cases of single substance exposures to aripiprazole, brexpiprazole, cariprazine, or lumateperone in children ages 0 to 5 years old with follow-up to a known outcome. Key outcomes were medical outcomes, clinical effects, and level of care if treated in a healthcare facility.

RESULTS

There were 3,573 aripiprazole, 137 brexpiprazole, 249 cariprazine, and one lumateperone exposure over the period. Primary outcomes were evaluated in 2,655 cases (2,390 aripiprazole, 96 brexpiprazole, and 169 cariprazine). Fifty-one percent were male and 77% were between 0 and 2 years old. Moderate effect was coded in 16.6% of aripiprazole, 23% of brexpiprazole, and 12% of cariprazine exposures. Major effect was coded in 0.6% of aripiprazole, 1% of brexpiprazole, and 2.4% of cariprazine exposures. Duration of symptoms was mostly between 8 and 24 h for 34.6% of aripiprazole, 30% of brexpiprazole, and 32% of cariprazine exposures. Over 60% of the children seen in a health care facility were discharged from the emergency department. The lowest doses resulting in at least a moderate effect and admission to a health care facility was 0.46 mg/kg for aripiprazole, 2.1 mg/kg for brexpiprazole, and 1.9 mg/kg for cariprazine. Important clinical effects included central nervous system depression, tremors, tachycardia, agitation, and vomiting.

CONCLUSION

Reported ingestions of aripiprazole, brexpiprazole, or cariprazine may result in neurologic symptoms like central nervous system depression or seizures in children. The prolonged duration of symptoms resulted in admission for at least a day for many cases. Further research should address optimal monitoring time and location for these exposures.

Recognising side effects of antipsychotics in children with intellectual disabilities

Risperidone and aripiprazole are increasingly used for behavioural indications in children and adolescents with intellectual disabilities, including autism. Although there are some reports in literature, the side effect profile in this population remains poorly defined and there is a need to raise awareness among clinicians across specialties. We present two patients with significant intellectual disabilities who developed extrapyramidal side effects (EPSE) including oculogyric crisis following risperidone and aripiprazole use. The onset of these side effects can be insidious and the non-specific nature of the presentation, for example, poor mobility and increased drooling on a background of severe intellectual disability, can lend itself to delay in recognition and reporting by families. There is also reduced awareness among paediatricians, which can further delay the treatment of this reversible condition. There needs to be ongoing vigilance for EPSE as they can develop years after treatment has been initiated.

[Aripiprazole use in children and adolescent psychiatric patients]

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

Efficacy and safety of aripiprazole in the treatment of bipolar disorder: a systematic review

BACKGROUND

The current article is a systematic review concerning the efficacy and safety of aripiprazole in the treatment of bipolar disorder.

METHODS

A systematic Medline and repositories search concerning the usefulness of aripiprazole in bipolar disorder was performed, with the combination of the words 'aripiprazole' and 'bipolar'.

RESULTS

The search returned 184 articles and was last updated on 15 April 2009. An additional search included repositories of clinical trials and previous systematic reviews specifically in order to trace unpublished trials. There were seven placebo-controlled randomised controlled trials (RCTs), six with comparator studies and one with add-on studies. They assessed the usefulness of aripiprazole in acute mania, acute bipolar depression and during the maintenance phase in comparison to placebo, lithium or haloperidol.

CONCLUSION

Aripiprazole appears effective for the treatment and prophylaxis against mania. The data on bipolar depression are so far negative, however there is a need for further study at lower dosages. The most frequent adverse effects are extrapyramidal signs and symptoms, especially akathisia, without any significant weight gain, hyperprolactinaemia or laboratory test changes.

A systematic review of cardiovascular effects after atypical antipsychotic medication overdose

As the use of atypical antipsychotic medications (AAPMs) increases, the number of overdoses continues to grow. Cardiovascular toxicity was common with older psychiatric medications but seems uncommon with AAPM. We conducted a systematic literature review to describe the cardiovascular effects reported after overdose of 5 common AAPM: aripiprazole, olanzapine, quetiapine, risperidone, and ziprasidone. We included case reports and case series describing overdose of these 5 medications identified in a search of MEDLINE, EMBASE, and abstracts from major toxicology meetings. We found 13 pediatric cases (age, <7 years), 22 adolescent cases (age, 7-16 years), and 185 adult cases. No pediatric case described a ventricular dysrhythmia or a cardiovascular death. In the adolescent and adult cases, we found numerous reports of prolonged corrected QT interval and hypotension, but there were only 3 cases of ventricular dysrhythmia and 3 deaths that may have been due to direct cardiovascular toxicity. The results from case series reports were similar to the single case report data. Our review suggests that overdose of AAPM is unlikely to cause significant cardiovascular toxicity.

Prolonged toxicity in a 2-year-old after accidental ingestion of aripiprazole

Aripiprazole (Abilify), or 7-{4-[4-(2,3-dichlorophenyl)-1-piperazinyl]butyloxy}-3,4-dihydro-2(1H)-quinolone, is a novel atypical antipsychotic possessing a long half-life. Although not a Food and Drug Administration-approved indication, low-dose aripiprazole is used to treat pediatric psychiatric conditions. Data regarding toxicity of low-dose aripiprazole ingestions in children are limited. We report the case of an accidental ingestion of two 5-mg aripiprazole tablets by a 2-year-old girl with a measured drug level of 160 ng/mL approximately 34 hours after ingestion. She exhibited marked lethargy, tremor, and tachycardia persisting over 72 hours. Emergency physicians, pediatricians, and psychiatrists should be aware of the potential for significant and prolonged toxicity in children even with relatively small-dose aripiprazole exposures.

Pharmacogenetic testing of CYP2D6 in patients with aripiprazole-related extrapyramidal symptoms: a case-control study

Aripiprazole is primarily metabolized by the polymorphic CYP2D6. We genotyped four children (aged 6-15 years) who had developed extrapyramidal symptoms within 1 week of aripiprazole initiation or dose titration, and four matched children without extrapyramidal symptoms. All of the four children who developed extrapyramidal symptoms with aripiprazole had a dysfunctional CYP2D6 enzyme, based on genotype, and were categorized as either intermediate metabolizers (n = 2) or poor metabolizers (n = 2). By contrast, only two children from the control group had either of these phenotypes, and both were intermediate metabolizers. Children with CYP2D6 abnormalities may be at higher risk of aripiprazole-induced adverse drug reactions.

A case of Aripiprazole and extra pyramidal side effects

This is a case report of a 56-year-old lady who was admitted to a psychiatric ward because she was showing a plethora of positive and negative symptoms of schizophrenia. She has a positive history of mental illness; her mother had a diagnosis of schizophrenia. The patient did not have any medical history of relevance and was not taking any medication. She was commenced on Aripiprazole and after 5 weeks developed disabling extra-pyramidal side effects. On discontinuation of Aripiprazole, the side effects subsided and disappeared quickly. According to the authors' knowledge, this is the first case of a patient developing extra-pyramidal side effects following treatment with Aripiprazole, not previously exposed to other antipsychotic, and with no co-morbid medical conditions. The authors suggest titrating Aripiprazole slowly.

Acute dystonia with low-dosage aripiprazole in Tourette's disorder

OBJECTIVE

To report a case of an acute dystonic episode in a patient with Tourette's disorder (TD) treated with the partial dopamine agonist aripiprazole.

CASE SUMMARY

An 18-year-old male with TD was prescribed aripiprazole 10 mg orally daily, which produced a significant improvement in his symptoms. However, after 3 days of treatment, he experienced an acute episode of dystonia with facial muscle spasm, oculogyric crisis, and torticolis. All symptoms resolved after a single intramuscular injection of biperidine 5 mg. The Naranjo probability scale indicated that the adverse events were probably caused by aripiprazole.

DISCUSSION

To our knowledge, as of this writing, this is the first report concerning an aripiprazole-induced dystonic episode in an adult, and it is especially notable because it occurred at low dosage. Aripiprazole is a dopamine partial agonist and a serotonin(2A) antagonist with a favorable adverse effect profile. Short-term clinical trials reported a very low incidence of extrapyramidal symptoms, with akathisia being the most common, although there have been reports of severe extrapyramidal symptoms in a 3-year-old child and in an adolescent with a previous history of such symptoms.

CONCLUSIONS

Acute dystonic phenomena may be caused by aripiprazole, although the drug's suggested mode of action largely precludes them.

Recognizing and monitoring adverse events of second-generation antipsychotics in children and adolescents

Although second-generation antipsychotics (SGAs) are used increasingly in children and adolescents, data on the effectiveness and safety in pediatric populations are still sparse. Much of the safety information is derived from studies conducted in adults. This derivation is problematic because children and adolescents are exposed to SGAs during a phase of unparalleled physical and psychologic development that can affect pharmacokinetic and pharmacodynamic drug actions, efficacy, and side-effect patterns. This article presents an overview of SGA-related side effects in children and adolescents and strategies to monitor health outcomes effectively in youngsters receiving SGAs.

Overdoses and ingestions of second-generation antipsychotics in children and adolescents

OBJECTIVE

We reviewed the available published data on intentional or unintentional secondgeneration antipsychotic overdoses in children and adolescents. The prescribing of secondgeneration antipsychotics has continued to increase over the past decade for children, adolescents, and adults. The authors reviewed the existing literature to determine the circumstances, presenting problems, treatment, and outcomes of youths who were exposed to nontherapeutic doses of these medications.

METHODS

A systematic English-language Medline search of all reports (1989-2005) and a review of the bibliographies of all articles obtained was done to identify papers reporting an overdose or ingestion of a second-generation antipsychotic. Data were reviewed on clozapine, risperidone, olanzapine, ziprasidone, quetiapine, and aripiprazole. The annual reports of the American Association of Poison Control Centers National Data Collection System were reviewed from 1990 to 2003, the most recent report currently available. All fatalities in children and youths under 18 years of age were included.

RESULTS

The literature review identified 40 reports that included 63 patients, ranging in age from 1 day to 17 years of age. The clinical presentations included drowsiness, lethargy, agitation, irritability, combativeness, and tachycardia. There were 11 fatalities in the cases reviewed, 1 from clozapine overdose, 3 from risperidone overdose, 2 from olanzapine overdose, and 5 from quetiapine overdose. All other cases reported no significant sequelae and resolved without any reported clinical consequences. Duration of overdose symptoms ranged from 24 hours to 7 days. One case of clozapine intoxication showed resolution of symptoms in 6 hours and, in another case of olanzapine overdose, symptoms resolved in 13 days. The most frequently employed treatments included intubation, gastric lavage, activated charcoal, intravenous fluids, artificial respiration, and restraints or sedatives.

CONCLUSIONS

There is a need for future case reports to include serum medication level, weight of patient, coingestants, the health of the patient at baseline, relevant laboratory and toxicology studies and a standardized scale to rate the level of consciousness, such as the Glasgow Coma Scale. The existing pharmacovigilance data reports indicate these medications are relatively safe when taken in overdose, particularly when coingestants are not involved.