Atypical Antipsychotics Safety and Use in Pediatric Patients: Perspectives for Pharmacists
Decisions about medications can often be life and death choices, whether the experts realize it or not. When it comes to giving atypical antipsychotics to children, the results reflect this difference, letting kids and their families actually live life versus sinking into constant struggle. At the same time, antipsychotics begun at a young age open the door to the risk of serious health consequences. To provide the best patient counselling—to give parents the best guidance when faced with such extreme options—pharmacists need to understand the seldom-discussed obstacles that influence parental decisions.
Use of Atypical Antipsychotics in Children
A brief history of antipsychotic use in children looks something like this: following a 65 percent increase in prescriptions between 2002 and 2009, the news became worse when a study found a twofold to fivefold rise in antipsychotic use in preschool children.1 Then researchers began to report significant disparities in antipsychotics between those with private health insurance versus Medicaid-insured children. Off-label use also rose, accounting for 65 percent of atypical antipsychotics prescribed for four to 18-year-olds.2
Now recently published statistics show that the upward trend in prescriptions peaked in 2008 and atypical antipsychotic (AAP) use has slightly decreased.3 Today’s levels are still higher than before, but at least the escalation has stopped. The numbers started to change as oversight programs for Medicaid recipients were implemented. Each state develops its own standards, but examples of requirements include:4
Signed consent form: The prescriber must obtain signed informed consent stating the targeted symptoms and adverse effects of the medication. Some states only require documentation to be on file, while others have prescribers fax documents to the appropriate state agency.
Manual review by a child psychiatrist: Some states review every antipsychotic prescription that meets their criteria, such as:
- Antipsychotics prescribed for children below a certain age, usually 6 or 7.
- Requests for any additional antipsychotic agents.
- Doses higher than the recommended amount.
- Specific drugs as determined by the state.
Monitor side effects: Testing and documentation of indices such as weight, blood pressure, blood glucose, and blood lipids.
Pre-approval: States may require prescribers to get pre-approval for AAP prescriptions when they’re being used off label or when the patient is below a specified age.
Impact on Patients and Perspective for Pharmacists
While statistics have leveled off, experts in the field, including the authors of a study in JAMA Psychiatry, are worried about data showing that AAPs are primarily prescribed for aggression in children. They say that antipsychotics should only be used when behavioral therapies have failed—that they’re a treatment of last resort.5 Their concerns are grounded in a lack of long-term studies and the potential for known and unknown adverse effects.
There’s no way to argue with these legitimate health issues. But here’s the thing pharmacists need to know as they have the opportunity to counsel these families: concerns raised by experts don’t begin to tell the whole story. Sometimes families don’t have a choice of treatments, yet the studies don’t discuss real world factors that influence medication decisions, such as:
Behavioral challenges: Two AAPs—risperidone and aripiprazole—are FDA-approved for “irritability” in children with autism, but this is often a euphemism for aggression. Experts hesitate to associate aggression with autism because it leads to the false conclusion that autistic kids are dangerous. But the following core autistic traits lead to pent-up anxiety that finds a release in aggressive behaviors:
- Hypersensitivity – inability to accurately process sensory information.
- Cognitive differences
- Inability to interpret social cues
- Difficulty communicating
Aggression related to autism can take the form of kids who can’t calm down for hours, destroy property, hit caregivers or engage in self harm. Their behavior may lead to school suspension, destroy friendships and ruin their self-esteem.6 Aggression can also make it difficult for these kids to be receptive to behavioral therapy, but AAPs make an immediate improvement. For these young patients, AAPs are not the treatment of last resort—they’re life changers.
Lack of services: The experts offer sound advice when they advise non-pharmaceutical options before turning to AAPs. Here’s a little-known fact that influences treatment choices: All but a few states have waiting lists for behavioral services. Kids who need therapy must wait anywhere from one to 10 years to get therapy if the family can’t pay out-of-pocket. In real numbers, that means roughly 268,000 children wait to get the therapy needed to avoid taking antipsychotics.7
Shortage of professionals: The American Academy of Child and Adolescent Psychiatry (AACAP) says there’s a critical shortage of child psychiatrists.8 There’s also a chronic shortage of social workers and direct care professionals who implement behavioral therapy. The experts say that fewer than one-quarter of children get the behavior modification and family therapy that should come before medication. But therapy isn’t an option when professionals aren’t available.
Pharmacist Outreach with Greater Compassion
As a pharmacist, you’re the expert on the adverse effects of atypical antipsychotics and are responsible for making sure parents understand those risks. But as you approach counseling, temper strong advice from the experts with the type of compassion that only comes from knowing that choices are sometimes limited. Don’t forget you may be able to make their life easier by talking about compounding options that help kids take their medications—another major issue faced by parents. Make yourself an ally in health care by showing these parents that you really do understand the roadblocks they face.
Pharmaceutica North America stays up-to-date with research and welcomes the opportunity to support all of your patients. We provide high-quality prescription products, injection kits, bulk Active Pharmaceutical Ingredients, and compounding kits. Please contact us today so we can talk and answer your questions.
- “Antipsychotic Medication Prescribing Trends in Children and Adolescents,” September 2013, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3778027/ ↩
- “National Trends in Off-Label Use of Atypical Antipsychotics in Children and Adolescents in the United States,” June 2016, http://www.ncbi.nlm.nih.gov/pubmed/27281081 ↩
- “Have Efforts to Slow the Rapid Increase in Antipsychotic Use in Children on Medicaid Worked?” July 2016, http://www.ajmc.com/newsroom/have-efforts-to-slow-the-rapid-increase-in-antipsychotic-use-in-children-on-medicaid-worked ↩
- “A Review of State Medicaid Approaches on Child Antipsychotic Monitoring Programs,” January 2016, https://www.medicaid.gov/medicaid-chip-program-information/by-topics/benefits/prescription-drugs/downloads/state-medicaid-dur-summaries.pdf ↩
- “Antipsychotics Too Often Prescribed for Aggression in Children,” July 2015, http://www.npr.org/sections/health-shots/2015/07/01/418935734/antipsychotics-too-often-prescribed-for-aggression-in-children ↩
- “Aggression in Autism Spectrum Disorder: Presentation and Treatment Options,” June 2016, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4922773/ ↩
- “Disability Services and Waivers,” 2014, http://medicaidwaiver.org/ ↩
- “AACAP: Workforce Issues,” February 2016, http://www.aacap.org/aacap/resources_for_primary_care/Workforce_Issues.aspx ↩