Psychiatric Treatment Approaches for Pediatric Pain
Andrea Kohn Maikovich-Fong in Handbook of Psychosocial Interventions for Chronic Pain, 2019
Published studies evaluating the utility of antipsychotics for chronic pain have been uncontrolled (Khouzam, 2016), and due to long-term concerns for metabolic side effects, use in children should be limited. Antipsychotic agents may have relevance for severe behaviors such as obsessional thinking, severe agitation, or destructive self-harm behaviors, often exacerbated by severe chronic pain in youth. Atypical antipsychotic agents have broader receptor profiles than traditional antipsychotics (which primarily act through D2 blockade), including blockade of serotonin 2A receptors. This is thought to enhance dopamine release in specific brain regions, possibly mitigating against some motor and cognitive side effects. Children may be more sensitive to the side effects of antipsychotics, and use of these medications in children should be monitored even more closely than in adults. Risperidone is the most commonly used antipsychotic agent in children and adolescents, approved for use in teens with schizophrenia and other psychotic disorders, for acute mania in children over 10, and for agitation and irritability in children with ASD over 5. Risperidone can be used at very low dosages and administrated in various formulations (liquid, pill, dissolvable tablet), but cannot be compelled intramuscularly or intravenously, limiting its use for acute agitation in an uncooperative patient. It is commonly associated with sedation and weight gain and carries greater risk of hyperprolactinemia and extrapyramidal motor impairments as compared to other atypical antipsychotics. Risperidone has shown limited benefits in small studies of adults with fibromyalgia and other chronic pain conditions, with mild reductions in pain severity and improvements in measures of psychosocial functioning (Davis, Chen, & Glick, 2003). However, its limited evidence base and association with problematic long-term side effects limits its use for youth with chronic pain in the absence of other severe psychopathology. Quetiapine is an atypical antipsychotic also approved for schizophrenia and bipolar mania in adolescents, as well as for depression in adults. This benefit, unique among antipsychotics, may come from partial agonism at 5HT1A receptors, particularly at higher dosages. At low doses (commonly used in youth), quetiapine primarily exhibits antihistaminergic properties, contributing to sedation and increases in appetite. Therefore, quetiapine often is used to address sleep problems in patients with severe depression or PTSD to reduce hypervigilance and cognitive perseveration and to normalize sleep architecture. It has shown adjunctive benefit when combined with SSRIs for several indications, including depression, PTSD, and severe anxiety disorders. In terms of addressing pain symptoms, quetiapine has revealed some benefits for adults with fibromyalgia and migraine disorders (Calandre & Rico-Villademoros, 2012), including improvements on measures of depressed mood. Yet most randomized trials have revealed negative results (Jimenez, Sundararajan, & Covington, 2018). Recent review suggested that quetiapine use may be considered for short-term approaches to reduce pain in fibromyalgia patients with comorbid depression while monitoring for problematic side effects, including weight gain (Walitt, Klose, Üçeyler, Phillips, & Häuser, 2016). Dry mouth and orthostatic hypotension also are common, with dizziness potentially limiting tolerance. Cardiac conduction abnormalities have been noted, particularly in patients with polypharmacy. Yet quetiapine is associated with a low rate of extrapyramidal motor effects and hyperprolactinemia.
Information on level of drugs into breastmilk
Wendy Jones in Breastfeeding and Medication, 2018
Brand name: Seroquel®US brands: Seroquel®Australian brands: Seroquel®Quetiapine has been associated with a low incidence of extra-pyramidal symptoms but tardive dyskinesia may occur after long-term treatment. The most frequent adverse effects with quetiapine are somnolence and dizziness. Weight gain, particularly during early treatment, has also been noted. It appears to have a minimal effect on prolactin levels. It is 98% plasma protein bound. The half-life is six–seven hours. Lee et al. (2004) studied one mother taking 200 mg daily throughout pregnancy. Breastfeeding was not initiated in the absence of safety data until measurement of her breastmilk samples were available. Levels measured indicated that an exclusively breastfed baby would normally ingest only 0.09% of the weight adjusted dose (maximum 0.43%). The mother initiated breastfeeding 8 weeks after delivery. Follow up at 4.5 months indicated normal development with no adverse effects. Misri et al. (2006) studied 6 mothers taking 25 to 400 mg daily together with an antidepressant.
Clinical vignettes
Alistair Burns, Michael A Horan, John E Clague, Gillian McLean in Geriatric Medicine for Old-Age Psychiatrists, 2005
Before considering the use of antipsychotic medication, some manipulation of the Parkinson medication should be attempted. These should be discontinued in the following order: anticholinergics; monoamine oxidase (MAO)-B inhibitors, e.g. selegiline; catechol-O-methyl- transferase (COMT) inhibitors, e.g. pergolide; dopamine agonists, e.g. bromocriptine. If these measures are ineffective or the patient is not receiving any of these treatments, then the L-dopa therapy must be reviewed. Ideally, a reduction in the overall daily dose should be the aim, starting with a decrease initially in the nocturnal dose. Continued small reductions in the daily dose should be continued until either the psychosis settles or the patient's mobility begins to decline. At all times, assessment of the physical state should be made, subjectively, or by the use of a rating scale. When no further reduction in the L-dopa can be made without significant decline in function, the introduction of a small dose of antipsychotic must be considered. All antipsychotics carry some risk of exacerbating parkinsonian symptoms. The atypical antipsychotics carry the least risk, with a propensity to develop extrapyramidal side-effects in the order: risperidone > olanzapine > quetiapine > clozapine. Due to its complex monitoring and risk of blood dyscrasias, clozapine is rarely used. A small dose of quetiapine, e.g. 25 mg, may therefore be helpful as an alternative. Aripiprazole has reportedly no more risk of producing extrapyramidal symptoms than placebo, and may prove to be beneficial. It acts as a dopamine system stabiliser, agonistic in dopamine-depleted systems, and antagonistic in systems where dopamine is produced in excess. The starting dose can be as low as 5 mg daily. The aim of therapeutic manipulation is to minimise psychiatric morbid- ity, whilst retaining or maximising physical function. A delicate balancing act often ensues, and some compromise of function may have to take place.
Tardive dyskinesia in a patient treated with quetiapine
Published in The World Journal of Biological Psychiatry, 2009
Emmanouil Rizos, Athanassios Douzenis, Rossetos Gournellis, Christos Christodoulou, Lefteris P. Lykouras
Quetiapine is an atypical antipsychotic that is believed to have a low D2 binding affinity in striatal and extrastriatal regions. We report the case of a female patient with the diagnosis of schizoaffective disorder (using DSM-IV-TR criteria) who initially received amisulpride for 3 months, discontinued gradually because of persistent and distressing extra-pyramidal symptoms, and who developed tardive dyskinesia 3 months later after the initiation of quetiapine. A trial with ziprasidone resulted in a further worsening of tardive dyskinesia symptoms. A further trial with aripiprazole, improved her tardive dyskinesia symptoms. Although, it is under consideration the possibility that the improvement could have been due to the discontinuation of quetiapine, we conclude that aripiprazole improved the TD symptoms.
Two cases of priapism associated with Quetiapine
Published in Psychiatry and Clinical Psychopharmacology, 2018
Özge Şahmelikoğlu Onur, Hatice Kızılkale, Hüseyin Yumrukçal, Meltem Gürü
Priapism is a painful, prolonged erection that occurs without any sexual stimulation. It is an emergency that may lead impotence, urinary retention, and gangrene as long-term devastating consequences. Priapism is attributed to the blockage of alpha-1 adrenergic receptors in the corpus cavernosum and associated with the use of typical antipsychotics, notably, thioridazine. Atypical antipsychotics are increasingly being prescribed and not frequently considered to cause priapism. This side effect has been reported in patients taking ziprasidone, risperidone, clozapine, quetiapine, aripiprazole and olanzapine. The intensity of binding to alpha-1 adrenergic receptors varies among all antipsychotics; quetiapine has an intermediate affinity. Priapism may be an idiosyncratic reaction which is correlated neither with the dosage nor the duration of use of antipsychotic drug. Quetiapine has been implicated in causing priapism in a limited number of reports. A history of prolonged erections may be a possible predictor of priapism during the use of quetiapine. We report two cases of priapism associated with quetiapine and a brief review.
Quetiapine Dependence and Withdrawal: A Case Report
Published in Substance Abuse, 2011
ABSTRACT Quetiapine is a new-generation antipsychotic medication approved in the treatment of schizophrenia, bipolar disorder, and related disorders. There are reports about the abuse and possible dependence of quetiapine. We present the first case of definite quetiapine dependence. This is a 37-year-old male who applied to the addiction unit because he could not control quetiapine use. He had a history of alcohol and benzodiazepine dependence as well as cannabis abuse. He reported to have a rush on quetiapine and suffered from its withdrawal when he tried to wean off the medication. This case and similar other suggest that while quetiapine may be beneficial in the treatment of some patients with addictive disorders, we should be cautious when using quetiapine to treat patients with drug or alcohol dependence.
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