Metabolic consequences of second-generation antipsychotics in youth: appropriate monitoring and clinical management

Real-world effectiveness of repeated intravenous ketamine infusions for treatment-resistant depression in transitional age youth

BACKGROUND

Ketamine is an emerging treatment for treatment-resistant depression (TRD) associated with rapid and robust improvements in depressive symptoms and suicidality. However, the efficacy and safety of ketamine in transitional age youth (TAY; age 18-25) populations remains understudied.

METHODS

In this retrospective analysis, TAY patients (n = 52) receiving ketamine for TRD were matched for sex, primary diagnosis, baseline depression severity, and treatment resistance with a general adult (GA) sample (age 30-60). Patients received four ketamine infusions over 2 weeks (0.5-0.75 mg/kg over 40 min). The primary outcome was the change in Quick Inventory of Depressive Symptomatology Self-Report 16-item (QIDS-SR16) over time. Secondary outcomes were changes in QIDS-SR16 suicidal ideation (SI) item, anxiety (Generalized Anxiety Disorder 7-item (GAD-7)), and adverse effects (ClinicalTrials.gov: NCT04209296).

RESULTS

A significant main effect of infusions on reduction of total QIDS-SR16 (p < 0.001), QIDS-SR16 SI (p < 0.001), and GAD-7 (p < 0.001) scores was observed in the TAY group with moderate effect sizes, indicative of clinically significant improvements in depression, anxiety, and suicidality. There were no significant differences between TAY and GA groups on these measures over time, suggesting comparable improvements in both groups. Safety and tolerability outcomes were comparable between groups with only mild, transient adverse effects observed.

CONCLUSION

Ketamine was associated with comparable clinical benefits, safety, and tolerability in a TAY sample as compared to a matched GA TRD sample.

Acceptability, equity, and feasibility of using antipsychotics in children and adolescents with autism spectrum disorder: a systematic review

BACKGROUND

It is unclear whether the administration of antipsychotics to children and adolescents with autism spectrum disorders (ASD) is acceptable, equitable, and feasible.

METHODS

We performed a systematic review to support a multidisciplinary panel in formulating a recommendation on antipsychotics, for the development of the Italian national guidelines for the management of ASD. A comprehensive search strategy was performed to find data related to intervention acceptability, health equity, and implementation feasibility. We used quantitative data from randomized controlled trials to perform a meta-analysis assessing the acceptability and tolerability of antipsychotics, and we estimated the certainty of the effect according to the GRADE approach. We extracted data from systematic reviews, primary studies, and grey literature, and we assessed the risk of bias and methodological quality of the published studies.

RESULTS

Antipsychotics were acceptable (dropouts due to any cause: RR 0.61, 95% CI 0.48-0.78, moderate certainty of evidence) and well tolerated (dropouts due to adverse events: RR 0.99, 95% CI 0.55-1.79, low certainty of evidence) by children and adolescents with ASD. Parents and clinicians did not raise significant issues concerning acceptability. We did not find studies reporting evidence of reduced equity for antipsychotics in disadvantaged subgroups of children and adolescents with ASD. Workloads, cost barriers, and inadequate monitoring of metabolic adverse events were indirect evidence of concerns for feasibility.

CONCLUSION

Antipsychotics in children and adolescents with ASD were likely acceptable and possibly feasible. We did not find evidence of concern for equity.

[Challenges of the use of antipsychotics in children and adolescents]

The more frequent prescription of antipsychotics with high proportion of off label use, in particular for children and adolescents, is seen in many countries, including European Union, United States and Russian Federation. In accordance to current clinical guidelines, second-generation antipsychotics are preferred in clinical practice due to the higher tolerability compared to the first-generation antipsychotics. However, second-generation antipsychotics in children and adolescents, especially in continuous use, are associated with cardiac abnormalities and metabolic disorders, including hyperglycemia, and the risk of type 2 diabetes, weight gain and obesity, an increase in prolactin synthesis and hyperlipidemia. The adverse effects of antipsychotics in children and adolescents determine the need for more balanced approaches to their use, careful monitoring of the safety of treatment and the development of measures to prevent and correct side-effects of these drugs.

Metabolic monitoring in children 5 years of age and younger prescribed second-generation antipsychotic medications

INTRODUCTION

The objective of this article was to identify the rates of patients ≤5 years of age who received recommended monitoring before and after second-generation antipsychotic (SGA) initiation and had an SGA metabolic adverse effect (MAE).

METHODS

This was a retrospective cohort analysis conducted at Kaiser Permanente Colorado, an integrated health care delivery system, between January 1, 2002, and June 30, 2011. Commercially insured patients ≤5 years of age newly initiated on an SGA were included. Patients were followed for up to 3 years. Metabolic monitoring included lipid profile, blood glucose, blood pressure, and weight measurements. Patient characteristics and outcomes were described using descriptive statistics.

RESULTS

A total of 40 patients were included. Overall, 2 (5.0%) patients received all recommended baseline monitoring, and no (0.0%) patients received all recommended follow-up monitoring. Weight monitoring was completed most frequently with rates of completion of 57.5%, 95.0%, 85.0%, and 76.5% at baseline and years 1, 2, and 3, respectively. At least 1 MAE was identified in 14/40 (35.0%), 5/28 (17.9%), and 2/17 (11.8%) patients during years 1, 2, and 3, respectively. The most frequent MAE identified was weight gain. Among patients identified with at least 1 MAE, 4/14 (28.6%), 2/5 (40.0%), and 2/2 (100%) received a behavioral intervention during years 1, 2, and 3, respectively.

DISCUSSION

Overall, baseline and follow-up metabolic monitoring were poor. Future studies should focus on examining barriers to monitoring in order to improve health care quality.

Common Medications Which Lead to Unintended Alterations in Weight Gain or Organ Lipotoxicity

Obesity is one of the most common chronic conditions in the world. Its management is difficult, partly due to the multiple associated comorbidities including fatty liver, diabetes, hypertension, and hyperlipidemia. As a result, the choice of prescription medications in overweight and obese patients has important implications as some of them can actually worsen the fat accumulation and its associated metabolic complications. Several prescription medications are associated with weight gain with mechanisms that are often poorly understood and under-recognized. Even less data are available on the distribution of fat and lipotoxicity (the organ damage related to fat accumulation). The present review will discuss the drugs associated with weight gain, their mechanism of action, and the magnitude and timing of their effect.