Anticholinergic Use in Children and Adolescents After Initiation of Antipsychotic Therapy

Abstract

Background Second generation antipsychotics (SGAs) are thought to have a lower likelihood of inducing extrapyramidal symptoms (EPS) than first generation antipsychotics (FGAs). Clinical observations suggest that younger patients may be more sensitive to SGA-associated EPS than adults and require therapy with anticholinergic agents, which are known to impair cognitive performance. The scope of anticholinergic use in this patient population and differences in utilization across SGAs (as well as FGAs) has not been extensively studied. Objective The primary objective of this study was to determine the proportion of patients five to 18 years of age who received anticholinergic therapy during the initial stages of antipsychotic treatment. A secondary objective was to compare anticholinergic use across patients receiving aripiprazole, risperidone, and quetiapine, SGAs previously identified to be the most commonly prescribed at the academic institution studied. Methods Patients five to 18 years of age initiating a trial of an antipsychotic between January 1, 2005 and September 1, 2008 were identified in a retrospective review of prescription and medical records. Demographic characteristics, antipsychotic and anticholinergic utilization, indications, diagnoses, and concomitant medications and doses were collected from the electronic medical record. For patients who received more than one therapeutic course of an antipsychotic during the identified timeframe, only the first course identified in the medical record was used for analyses. Anticholinergic utilization at antipsychotic initiation and after 30 days was assessed. Variables associated with anticholinergic use and differences across agents were identified. Results A total of 235 antipsychotic treatment courses were identified. Of these, 152 patients met our inclusion criteria and represented the first documented use of an antipsychotic at the present institution. Anticholinergic use at any time during the first 30 days of treatment was identified in 32 patients (21%) while EPS was documented for 12 patients (7.8%). FGA or polypharmacy defined as simultaneous use of ≥1 scheduled antipsychotic versus SGA (OR=18.98; 95% CI:4.74 – 75.95) was the primary characteristic significantly associated with anticholinergic use 30 days after initiation. Risperidone, quetiapine, and aripiprazole were the three most commonly prescribed antipsychotics. Of these SGAs, anticholinergic use was most frequently prescribed with risperidone treatment (p=0.03). Conclusion Anticholinergic use exceeded the incidence of EPS as documented in the electronic medical record (21% vs 8%) and differed across individual medications as well as antipsychotic class. Use of an FGA or polypharmacy was a key predictor of anticholinergic use.

Potentially Inappropriate Anticholinergic Medication Use in Community-Dwelling Older Adults: A National Cross-Sectional Study

“…This possibly suggests that prescribers are more careful and aware while prescribing anticholinergic medications to older adults. The study also found a gender-based variation consistent with previous findings [39]; females were 37 % more likely to use potentially inappropriate anticholinergic medications than their male counterparts. Further, older adults with [15 years of education were found to be 46 % less likely to use potentially inappropriate anticholinergic medications than older adults with \12 years of education.…”

Antipsychotic and Anticholinergic Drug Prescribing Pattern in Psychiatry: Extent of Evidence-Based Practice in Bahrain

“…In our study anticholinergics may have been routinely prescribed even in the absence of EPS, although experts disagree about the prophylactic use of these agents [16,18]. This therapeutic dilemma has been addressed by Gjerden et al [31] who viewed that anticholinergic use appears to be superfluous for at least one-third of patients, and their use exceeded the incidence of EPS [32].…”

Prevalence and correlates of antipsychotic polypharmacy in children and adolescents receiving antipsychotic treatment

“…Ten studies (75.0%) used the broadest definition of APP, requiring ≥1 d of antipsychotic co-treatments and five studies (25.0%) required antipsychotic co-treatment to last for >30 d (Morrato et al 2007), ≥60 d (Constantine et al 2010; dosReis et al 2011; Hong & Bishop, 2010) or ≥90 d (Kogut et al 2005). Moreover, two studies restricted the definition of APP to either a combination of risperidone with another antipsychotic (Simeon et al 2002), or to a combination of FGA+SGA (Wonodi et al 2007).…”