What are the guidelines for using antipsychotics, such as Risperidone (risperidone) and Aripiprazole (aripiprazole), in children?

Guidelines for Using Antipsychotics in Children

Atypical antipsychotics such as risperidone and aripiprazole should be used at the lowest effective doses in children, with risperidone typically started at 0.25-0.5 mg for children and 0.5-1 mg for adolescents, and aripiprazole at 2-5 mg for adolescents, with careful monitoring of metabolic and neurological side effects. 1

FDA-Approved Indications and Dosing

• Risperidone and aripiprazole are the only FDA-approved antipsychotics for treating irritability in autism spectrum disorder (ASD) 2
• For children with ASD, typical effective doses are:
  • Risperidone: 0.5-2 mg/day for children, 0.5-3.5 mg/day for adolescents 1
  • Aripiprazole: 5-15 mg/day for children and adolescents aged 6-17 years 1
• Initial target doses should be low, with examples of appropriate starting doses being:
  • Risperidone: 0.25-0.50 mg for children, 0.5-1 mg for adolescents 1
  • Aripiprazole: 2-5 mg for adolescents 1

Monitoring Requirements

• Baseline assessment before starting antipsychotics should include:

  • Weight, height, BMI calculation 3
  • Blood pressure and heart rate 3
  • Fasting glucose and lipid profile 3
  • Prolactin levels (especially for risperidone) 3
  • Extrapyramidal symptom assessment 1

• Ongoing monitoring should include:

  • Regular weight checks (monthly for first 3 months, then quarterly) 3, 4
  • Metabolic parameters (glucose, lipids) every 3-6 months 3
  • Prolactin levels, particularly with risperidone 3, 5
  • Cardiovascular parameters including heart rate 3
  • Assessment for emergence of extrapyramidal symptoms 1

Side Effect Profiles and Considerations

• Common side effects of antipsychotics in children include:

  • Weight gain (more pronounced with risperidone than aripiprazole) 3, 4
  • Increased heart rate (observed with both medications) 3
  • Hyperprolactinemia (significantly more common with risperidone) 3, 5
  • Extrapyramidal symptoms including dystonic reactions 1
  • Sedation and fatigue 1

• Specific medication differences:

  • Risperidone causes significant increases in prolactin levels over time 3, 5
  • Aripiprazole may actually decrease prolactin levels 5
  • Both medications cause BMI increases, but monitoring is essential 3
  • Aripiprazole may have slightly better tolerability in some children 3

Medication Management Strategies

• Atypical antipsychotics are preferred over typical antipsychotics due to fewer extrapyramidal side effects 1
• When discontinuing antipsychotics, gradual tapering is recommended to avoid rebound worsening of symptoms 1
• For children on multiple medications:
  • If using an antipsychotic as an augmenting agent, it should typically be the first to be tapered when considering discontinuation 1
  • When comparing an antipsychotic to other mood stabilizers like lithium, the antipsychotic should generally be tapered first due to long-term safety profile considerations 1
  • Maintain anticholinergic medication well after antipsychotic discontinuation if it was needed for extrapyramidal symptoms 1

Special Considerations

• Head-to-head comparisons show comparable efficacy between risperidone and aripiprazole for treating irritability in ASD 2, 5
• The choice between risperidone and aripiprazole should be based on:
  • Side effect profile concerns (prolactin elevation with risperidone vs. minimal effect with aripiprazole) 5
  • Patient-specific factors and previous response 2
  • Metabolic risk factors 3, 4
• Long-term use (>12 weeks) shows continued efficacy but requires vigilant monitoring of side effects, particularly weight gain 4
• The use of antipsychotics in children has increased significantly in recent years, highlighting the need for appropriate monitoring and follow-up 6

Cautions and Contraindications

• Avoid antipsychotics with anticholinergic properties in patients presenting with intoxication from anticholinergic drugs or anticholinergic delirium 1
• Use lower doses in younger children and titrate more cautiously 1
• Consider potential drug interactions, particularly with medications that affect cytochrome P450 enzymes 3
• Be vigilant for emergence of metabolic syndrome, which can develop more rapidly in children than adults 3, 4