Tolerability, Safety, and Benefits of Risperidone in Children and Adolescents with Autism: 21-Month Follow-up After 8-Week Placebo-Controlled Trial

OBJECTIVE

Risperidone has demonstrated efficacy for acute (8 week) and intermediate length (6 month) management of severe irritability and aggression in children and adolescents with autism. Less is known about the long-term effects of risperidone exposure in this population. We examined the tolerability, safety, and therapeutic benefit of risperidone exposure over a 1-2 year follow-up period.

METHODS

In a naturalistic study, 84 children and adolescents 5-17 years of age (from an original sample of 101) were assessed an average of 21.4 months after initial entry into a placebo-controlled 8 week trial of risperidone for children and adolescents with autism and severe irritability. They were assessed at baseline and at follow-up on safety and tolerability measures (blood, urinalysis, electrocardiogram [ECG], medical history, vital signs, neurological symptoms, other adverse events), developmental measures (adaptive behavior, intelligence quotient [IQ]), and standardized rating instruments. Treatment over the follow-up period, after completion of protocol participation, was uncontrolled. Statistical analyses assessed outcome over time with or without prolonged risperidone therapy.

RESULTS

Two-thirds of the 84 subjects continued to receive risperidone (mean 2.47 mg/day, S.D. 1.29 mg). At follow-up, risperidone was associated with more enuresis, more excessive appetite, and more weight gain, but not more adverse neurological effects. No clinically significant events were noted on blood counts, chemistries, urinalysis, ECG, or interim medical history. Regardless of drug condition at follow-up, there was considerable improvement in maladaptive behavior compared with baseline, including core symptoms associated with autism. Height and weight gains were elevated with risperidone. Social skills on Vineland Adaptive Behavior Scale (VABS) improved with risperidone. Parent-rated Aberrant Behavior Checklist (ABC) Irritability subscale scores were reduced in those taking risperidone at follow-up. Several other measures of maladaptive behavior (some related to socialization) also showed improved functioning in association with risperidone on the ABC or on the Modified Real Life Rating Scale.

CONCLUSIONS

Increased appetite, weight gain, and enuresis are risks associated with long-term risperidone. Our data suggest that these risks were balanced by longer-term behavioral and social benefits for many children over 1.8 years of ongoing treatment.

Secondary enuresis & body dysmorphic disorder in a caucasian male with catatonic schizophrenia: a case report

We describe a patient with Schizophrenia and secondary enuresis. The enuresis settled with resolution of his psychotic symptoms but later remerged after starting Clozapine. We explore the mechanisms of incontinence in Schizophrenia and those due to Clozapine. This case highlights the need to inquire about incontinence in patients with schizophrenia prior to prescribing clozapine.

Use of aripiprazole in clozapine induced enuresis: report of two cases

This report describes the efficacy of combined use of aripiprazole in the treatment of a patient with clozapine induced enuresis. Aripiprazole acts as a potential dopamine partial agonist and the dopamine blockade in the basal ganglia might be one of the causes of urinary incontinence and enuresis. We speculate that aripiprazole functioned as a D2 agonist in hypodopaminergic state of basal ganglia caused by clozapine and maintained dopamine level that would improve enuresis ultimately.

[Enuresis in therapy with psychotropic drugs]

Ein 66-jähriger Patient mit einer bekannten bipolaren affektiven Störung wird mit Efexor®, Trittico®, Reminyl®, Stilnox® und Dipiperon® behandelt. Unter dieser Medikation entwickelt er eine Enuresis. Nach dem Absetzen von Dipiperon® sistiert die Enuresis innerhalb von 48 Stunden. Diese seltene unerwünschte Arzneimittelwirkung des Neuroleptikums ist wahrscheinlich eine extrapyramidale Nebenwirkung und auf eine Dysbalance der zentral wirkenden Neurotransmitter zurückzuführen.

Unusual side-effects due to clobazam: a case report with genetic study of CYP2C19

We describe the case of a 10-year-old girl with two epileptic seizures and subcontinuous spike-waves during sleep, who presented unusual side-effects related to clobazam (CLB) monotherapy. High plasma levels of N-desmethyl-clobazam (N-CLB), the major metabolite of CLB were detected. The patient and her parents underwent molecular analysis of the CYP2C19 gene, which may be implicated in the metabolism of this drug. Our patient presents one copy of the most common mutation (CYP2C19*2) affecting the activity of the isoenzyme and probably another rare or private mutation. CLB and N-CLB plasma level dosages and molecular analysis may be useful when a poor metabolic condition is suspected.

Paroxetine-induced enuresis

I would like to include one case to the literature on children and adolescents who have developed enuresis while taking paroxetine. Up to now, the fact that enuresis may have occurred as a result of the side effect of using paroxetine was not reported in some articles and letters.

Failure of tolterodine to treat clozapine-induced nocturnal enuresis

OBJECTIVE

To report the use and subsequent failure of the bladder-selective agent tolterodine, to treat clozapine-induced nocturnal enuresis in an adolescent patient with psychotic illness.

CASE SUMMARY

A 16-year-old Hispanic girl was admitted to the state psychiatric hospital with a diagnosis of bipolar disorder with psychotic features. Clozapine therapy was initiated, and after three months of treatment the patient began experiencing episodes of nocturnal enuresis. The bladder-selective agent tolterodine was tried and subsequently failed to resolve the enuresis episodes. Desmopressin was initiated, which resulted in amelioration of symptoms.

DISCUSSION

This is the first published report of using tolterodine to treat clozapine-induced nocturnal enuresis. Several methods to decrease clozapine-induced urinary incontinence have been used and typically include the addition of agents with high anticholinergic properties. Tolterodine is a bladder-selective anticholinergic agent indicated for the treatment of urinary urge incontinence and may be employed as a treatment for antipsychotic-induced incontinence.

CONCLUSIONS

Nocturnal enuresis is an adverse effect that infrequently occurs with use of clozapine therapy. Although tolterodine was ineffective in our patient to treat clozapine-induced nocturnal enuresis, further trials are required to appropriately evaluate the effectiveness of tolterodine to treat this adverse drug reaction.

Trihexyphenidyl as a possible therapeutic option in clozapine-induced nocturnal enuresis

Enuresis is an adverse event of clozapine treatment. The occurrence of nocturnal functional enuresis in two schizophrenic patients during the initial phase of clozapine therapy is reported. Beneficial effect of trihexyphenidyl administration (5 mg at 21.00 h) on clozapine-induced enuresis is clearly demonstrated in one patient. Trihexyphenidyl discontinuation and subsequent readministration in this patient led to corresponding recurrence and then disappearance of enuresis. Involvement of the cholinergic system has been proposed as one of the possible pathophysiological mechanisms of clozapine-induced enuresis.

Clozapine and urinary incontinence

Urinary incontinence may occur in patients with severe mental illness. Psychosis and neuroleptic medication have both been implicated, but there has been a lack of systematic evaluation of the precise relationship between these phenomena. Incontinence has been recognized as a complication of clozapine treatment and we examined this in 16 consecutively treated patients. Thirteen were established on therapeutic doses, one of whom was excluded from further study due to pre-existing incontinence. Retrospective assessment revealed that nocturnal incontinence was experienced by five of the remaining 12 patients, occurring in the first 3 months of treatment and resolving spontaneously in all cases. Incontinence was documented in the case notes in only one of the five cases and there was a tendency for affected patients to be embarrassed and reluctant to report it to staff. Specific enquiry may be necessary to elicit this phenomenon and incontinence should be considered as a possible factor in poor compliance with clozapine.

Safety and efficacy of human growth hormone treatment in girls with Turner syndrome

Six major adverse medical events (AMEs) and 44 minor AMEs were recorded in 6 and 23 patients, respectively, during human growth hormone (GH) treatment of Turner syndrome, equivalent to 118 treatment years. During the first year of GH treatment, there was no change in the SD score (SDS) for systolic or diastolic blood pressure. In a subgroup of 20 patients, there was no change in psychological tests, oral glucose tolerance, glycosylated haemoglobin or serum triglycerides over the first year of GH treatment. The mean total serum cholesterol level fell over this period. The low incidence of adverse medical problems during GH treatment complemented its efficacy. Height velocity in the first year was 7.7 +/- 1.8 cm/year (mean +/- SD) and was correlated with maternal height SDS, though not with paternal height SDS. Some 36% of first-year height velocity SDS could be predicted by the dose of GH and maternal height SDS.

A pharmacological paradigm for urinary incontinence and enuresis

The qualitative aspects of drugs used in enuresis control or associated with enuresis or urinary incontinence and the pathological disorders associated with enuresis or urinary incontinence are reviewed. The literature to date does not clarify the factors that account for tricyclic antidepressant effectiveness in enuresis. However, it does reveal that enuresis and urinary incontinence are common symptoms of basal ganglion disorders. Furthermore, pharmacological agents that depress or block dopamine activity produce urinary incontinence or enuresis, while those drugs augmenting the noradrenergic system facilitate continence. It is postulated that urinary incontinence and enuresis are secondary to an imbalance of catecholamine neurotransmitters within basal ganglion structures. A hypothesis is proposed suggesting that dopamine agonists could be viable therapeutic alternatives to tricyclics in treating enuresis and urinary incontinence. Additional clinical drug trials are needed to assess the characteristic responses of specific catecholamine agents in urinary incontinence and enuresis.

Pre-existing uninhibited bladder facilitating drug-induced enuresis: four case reports

The author presents four cases of antipsychotic drug-induced enuresis preceded by occult symptoms of mild uninhibited bladder. Pre-existing uninhibited bladder may facilitate some cases of antipsychotic drug-induced enuresis.

Lithium is an ineffective therapy for human cyclic hematopoiesis

Cyclic hematopoiesis is a rare disease in man in which severe neutropenia recurs at 21-day intervals with associated illness. Because lithium carbonate therapy has been shown to eliminate cyclic hematopoiesis in grey collie dogs, we examined the effects of lithium treatment on five patients with this disease. With lithium levels maintained between 0.5 and 1.0 meq/liter, these patients showed no change in the fluctuations of their neutrophil counts. We conclude that lithium carbonate is not a simple cure for human cyclic hematopoiesis.