Wednesday, 29 June 2016

Antipsychotic prescribing trends in autism meta-analysed

"Almost 1 in 10 antipsychotic-treated youth were diagnosed with ASD [autism spectrum disorder] and/or ID [intellectual disability], and 1 in 6 youth with ASD received antipsychotics."

The findings reported by Su Young Park and colleagues [1] have not surprisingly garnered some media attention (see here). Meta-analysing the available peer-reviewed data on "the frequency of youth diagnosed with ASDs and/or ID among antipsychotic-treated youth, as well as antipsychotic use in youth with ASD/ID", researchers came to some important conclusions when it came to prescribing patterns for the important class of medicines known as the antipsychotics. The focus was on youths this time around, complementing what is currently known about such medication use when it comes to adults (see here and see here) and a younger cohort (see here).

One or two details are worthy of promotion regarding the Park findings aside from the idea that antipsychotic use might not be unfamiliar when a diagnosis of autism is received: "In 5 longitudinal studies, the proportion of antipsychotic-treated youth with ASD did not change significantly from 1996 to 2011." That being said, the authors did note that later 'study time point' did seem to moderate "higher antipsychotic use among patients with ASD" and also among those with ASD/ID combined. This could indicate that reaching for the antipsychotic meds in response to things like 'challenging behaviour' is slowly becoming a little more common in recent times [2]; something that might have a few implications for corresponding health screening and monitoring for example (see here).

Indeed, in the accompanying media about their study, the authors make some interesting points: "Although the increased prescribing of antipsychotics in youth with autism spectrum disorders or intellectual disability cannot be judged as appropriate or inappropriate based on database studies, side effects of antipsychotics can be quite problematic, especially in children and adolescents." Additionally that: "clinicians should consider using psychosocial interventions that are proven to be efficient for behavioral dysregulation such as irritability and aggression, before prescribing antipsychotics to adolescents with autism or intellectual disability."

All I will say on the matter (with no medical or clinical advice given or intended) is that, yes, when faced with challenging behaviours, clinicians and others should always be first asking the question 'why' (see here) before immediately reaching for the antipsychotic or other meds. If and when important factors such as pain (see here) are ruled out, there may be grounds for the use of antipsychotic meds appropriate and proportionate to the scale of the behaviour(s) being presented, bearing in mind the name 'antipsychotic' provides the proper basis for such medication use [3]. But, as with any intervention of this type, the words 'time-limited experiment' should always be on the lips of the prescribing physician, allowing for the fact that the technology now exists to monitor things like plasma levels of various antipsychotics [4] and other important parameters routinely and mindful of what the research literature tells us about risks associated with such medicine use [5]. Said side-effects can include a variety of different issues [6].

Bear also in mind, that antipsychotics for 'tackling' challenging behaviour might not necessarily be the only option in future (see here)...

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[1] Park SY. et al. Antipsychotic Use Trends in Youth With Autism Spectrum Disorder and/or Intellectual Disability: A Meta-Analysis. J Am Acad Child Adolesc Psychiatry. 2016 Jun;55(6):456-468.e4.

[2] Satoh M. et al. Prescription trends in children with pervasive developmental disorders (PDD): A claims data-based study in Japan. World J Pediatr. 2016 Jun 10.

[3] Marston L. et al. Prescribing of antipsychotics in UK primary care: a cohort study. BMJ Open. 2014 Dec 18;4(12):e006135.

[4] Wijma RA. et al. Identification and quantification of the antipsychotics risperidone, aripiprazole, pipamperone and their major metabolites in plasma using ultra-high performance liquid chromatography-mass spectrometry. Biomed Chromatogr. 2016 Jun;30(6):794-801.

[5] Yu ZH. et al. Use of Antipsychotics and Risk of Myocardial Infarction: A Systematic Review and Meta-analysis. Br J Clin Pharmacol. 2016 May 16.

[6] Shirazi A. et al. Prevalence and Predictors of Clozapine-Associated Constipation: A Systematic Review and Meta-Analysis. Int. J. Mol. Sci. 2016, 17(6), 863

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ResearchBlogging.org Park SY, Cervesi C, Galling B, Molteni S, Walyzada F, Ameis SH, Gerhard T, Olfson M, & Correll CU (2016). Antipsychotic Use Trends in Youth With Autism Spectrum Disorder and/or Intellectual Disability: A Meta-Analysis. Journal of the American Academy of Child and Adolescent Psychiatry, 55 (6), 456-4680000 PMID: 27238064