PAL Newsletter  February 2019

Antipsychotic Use in Primary Care
 - By PAL Psychiatrist, Dr. Adam Klapperich
 
The use of second generation antipsychotics in the pediatric population is commonplace on inpatient psychiatric units and outpatient psychiatric clinics. Should this class of medications be in the primary care provider's "toolbox" of medications for their patients with behavioral and/or mood symptoms when the first and second-line medications fail?

There are currently seven second generation, or atypical, antipsychotics approved for use in children and adolescents. These include risperidone (irritability associated with autism, schizophrenia, bipolar disorder), aripiprazole (irritability associated with autism, schizophrenia, bipolar disorder), quetiapine (schizophrenia and bipolar disorder), olanzapine (schizophrenia and bipolar disorder), lurasidone (schizophrenia and bipolar disorder), paliperidone (schizophrenia), and asenapine (bipolar disorder).

The child or adolescent with schizophrenia or bipolar disorder is typically having medications managed by a psychiatric provider. However, children with autism spectrum disorder and major depressive disorder are often managed by primary care.

You may notice that augmentation of a SSRI medication with a second generation antipsychotic such as aripiprazole for major depression is not an FDA-approved use for adolescents. This use is only FDA approved for adults, so this would be off-label use, but also a reasonable strategy for augmenting treatment of depression in adolescent patients in the primary care clinic. I have found this to be helpful in adolescents who have partial benefit from SSRI or SNRI medication, but with residual symptoms of depression, especially irritability. A typical starting dose of aripiprazole for antidepressant augmentation is 1mg, which can be titrated to 2-5mg.

Both aripiprazole and risperidone can be quite helpful for managing behaviors and irritability in children with ASD. Aripiprazole can be started at 1mg daily, and titrated up to 5-10mg daily depending on tolerability. 1-2 mg is often a beneficial dose. Risperidone is started at 0.25mg daily, and titrated in increments of 0.25mg to max of 3mg total daily dose. Oftentimes 0.25mg BID is a beneficial dose.

The most common side effect from these two medications is weight gain. Also there is the risk of dyslipidemia and development of type 2 diabetes. Fasting lipids and glucose should be obtained at baseline, and again after three months of treatment, and every year thereafter. Weight should be checked at each appointment. Some psychiatrists obtain a baseline prolactin level prior to initiation of risperidone, though not necessarily the community standard of practice. The risk of gynocomastia should be discussed with the patient and guardian prior to initiation.

Extrapyramidal side effects are a risk with second generation antipsychotics. There continues to be a risk of tardive dyskinesia, though is relatively rare when compared with first generation antipsychotics. Second generation antipsychotics also carry the risk of dystonic reaction, akathisia, and rarely neuroleptic malignant syndrome.
EKG is not routinely obtained when starting aripiprazole or risperidone. This can be considered in a patient with a history of arrhythmia, or if used in combination with other potentially QT-prolonging medications (guanfacine/clonidine or stimulant medication, high dose (30-40mg) citalopram).

Another consideration with risperidone and aripiprazole specifically is their drug-drug interaction with fluoxetine (and paroxetine, though this is not routinely used in children). These SSRI medications inhibit the metabolism of both risperidone and aripiprazole, so lower starting doses are advised. Children with known deficiency of cytochrome 2D6 metabolism should start on lower doses as well.
Sources:
  1. Prim Care Companion J Clin Psychiatry. 2002; 4(6): 233-241.
  2. Atypical Antipsychotic Medications: Use in Pediatric Patients
  3. UpToDate Neuroleptic Malignant Syndrome

FREE CME coming to Hibbing and Mankato in 2019!
Pediatric Psychiatric Med Management and Trauma Care

The PAL team and a Nationally Certified Trauma Therapist provide FREE and CME-approved trainings for primary care providers and healthcare professionals that are focused on pediatric mental health assessment and treatment.

PAL will present from 8am-12pm on:
  • Overview of the Psychiatric Consultation Service and the importance of early identification of mental illness
  • Psychopharmacology (eg. Stimulants, SSRI's, SGA's, and Mood Stabilizers)
  • Metabolic Monitoring
  • Pharmacogenomics testing
  • Community Resources, Fast-TrackerMN.org, and collaborative care models
 Trauma Care therapist and trainer will present from 1-5pm on:
  • Psychotherapeutic modalities with a particular focus on evidence-based practices
  • Appropriate screening, referral and treatment of traumatic stress in children and youth
  • Ensuring adequate assessment and the appropriate diagnosis and treatment of ADHD in children and youth (e.g., differential diagnosis, alternatives to pharmaceutical treatments, etc.) 

PAL Psychiatrists 

Adam Klapperich, DO
Dr. Klapperich is a board certified child/adolescent and adult psychiatrist. He  joined PrairieCare Medical Group in Edina in 2012. He has since worked in inpatient, partial hospitalization, and outpatient settings at PrairieCare. Originally from Aberdeen, South Dakota, Dr. Klapperich attended the University of South Dakota before graduating from the Kirksville College of Osteopathic Medicine. He completed psychiatric residency and child and adolescent psychiatric fellowship training at the University of Minnesota. Dr. Klapperich works with children and adolescents in the newly opened Maplewood location.


Joshua Stein, MD
Dr. Stein is the clinical director and an attending clinician at the Brooklyn Park Partial Hospital Program (PHP) and operates a clinic out of the Brooklyn Park Medical Office Building. The clinic is used as a bridge for patient's leaving PHP until they can see their outpatient provider. Common goals for the PHP and clinic site are patient centered care that focuses on increasing functioning at home, functioning in school including extracurricular activities and in social settings. The focus for care is not just on immediate obstacles and gains, but improving long term trajectory as well. As the president of the Minnesota Society for Child Adolescent Psychiatry he focuses on local and national advocacy for children's mental health with a goal to increase access to quality care.
When is PAL available?
PAL is available Monday through Friday from 8:00 am to 6:00 pm! You can get more information and schedule by visiting us at www.mnpsychconsult.com  or by calling us at 855-431-6468. 
Prescribers can use PAL for medication consultation with our board certified Child & Adolescent Psychiatrist. Anyone in the community can use PAL for resource help.
PAL Informational Video: 

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Fast-Tracker is Minnesota's free, easy-to-use tool designed to  connect people with  resources and services. 

We connect individuals, families, mental health and substance use disorder providers, physicians, care coordinators, and others with a real-time, searchable directory of mental health and substance use disorder resources and their availability within Minnesota.

For more information, call Fast-Tracker 651-426-6347!

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