Atypical Antipsychotic Use among Medicaid-Insured Children and Adolescents: Duration, Safety, and Monitoring Implications

By Burcu, Mehmet; Zito, Julie Magno et al. | Journal of Child and Adolescent Psychopharmacology, April 2014 | Go to article overview

Atypical Antipsychotic Use among Medicaid-Insured Children and Adolescents: Duration, Safety, and Monitoring Implications


Burcu, Mehmet, Zito, Julie Magno, Ibe, Aloysius, Safer, Daniel J., Journal of Child and Adolescent Psychopharmacology


[Author Affiliation]

Mehmet Burcu. 1 Pharmaceutical Health Services Research, University of Maryland, Baltimore, Maryland.

Julie Magno Zito. 1 Pharmaceutical Health Services Research, University of Maryland, Baltimore, Maryland.

Aloysius Ibe. 2 School of Community Health and Policy, Morgan State University, Baltimore, Maryland.

Daniel J. Safer. 3 Department of Psychiatry and Pediatrics, Johns Hopkins Medical Institutions, Baltimore, Maryland.

Address correspondence to: Julie Magno Zito, PhD, Pharmaceutical Health Services Research, University of Maryland, 220 Arch St. Baltimore, 21201, E-mail: jzito@rx.umaryland.edu

Introduction

Over the last two decades, the increased use of second-generation antipsychotic medications, that is, atypical antipsychotics, has been profound (Olfson et al. 2002; Patel et al. 2005; Cooper et al. 2006; Olfson et al. 2006; Matone et al. 2012; Zito et al. 2013). This increased use has, however, occurred at a greater rate in youth that in adult populations (Olfson et al. 2012), mostly for publicly insured youth and for off-label (not approved by the United States Food and Drug Administration [FDA]) behavioral conditions, such as attention-deficit/hyperactivity disorder (ADHD) and other disruptive behavior disorders (Cooper et al. 2004; Crystal et al. 2009; Constantine et al. 2011, 2012; Zito et al. 2013). Compared with privately insured youth, youth in state Medicaid systems had five to sixfold greater antipsychotic use (Crystal et al. 2009), and by the calendar years 2006-2007, Medicaid-insured youth diagnosed with externalizing behavioral disorders by far represented the largest group of youth receiving antipsychotic medications (Matone et al. 2012; Zito et al. 2013).

The greatly expanded use of these agents in youth for ADHD occurred in the absence of FDA evidence-based labeling. Currently, atypical antipsychotic medications are FDA approved for use only in youth for schizophrenia, bipolar disorder, and irritability associated with autism, based on evidence from short-term randomized clinical trials. However, children and adolescents treated in community settings can vary sizably from clinical drug trial populations, and may often have substantially different psychotropic drug treatment outcomes. Several community-based studies have raised safety concerns for the use of atypical antipsychotic agents in children regarding treatment-emergent adverse events related to weight gain (Calarge et al. 2009; Correll et al. 2009; Andrade et al. 2011). Such treatment-emergent weight gain was found to be substantially greater in youth than in adults, according to secondary analysis of published clinical trial data (Safer 2004). To date, no atypical antipsychotic agent has an FDA-labeled indication for use in behavioral disorders in children and adolescents, underlying the urgent need for careful scrutiny of the duration of atypical antipsychotic use and the reasons for their use, according to clinician-reported psychiatric diagnosis.

In 8 week, open-label, clinical studies of olanzapine, risperidone, and quetiapine among preschool children, significant treatment-emergent cardiac and metabolic abnormalities were identified (Biederman et al. 2005; Joshi et al. 2012). In another study comparing short-term and long-term antipsychotic-emergent safety outcomes in children, children treated with longer durations of antipsychotic agents had greater cardiometabolic adversities and dyskinetic movements (Laita et al. 2007), warranting the need to assess patterns of atypical antipsychotic use in relation to their duration by age group and psychiatric diagnosis. A recent study also pointed out a trend of concomitant use of multiple antipsychotic agents among Medicaid-insured youth in a mid-Atlantic state (dosReis et al. 2011). Of youth with antipsychotic dispensings,>10% used two or more antipsychotic agents concomitantly (dosReis et al. …

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