Subject:
(Scahill L et al, J Am Acad Adolesc Psychiatry 2016;55(5):415–423)

Short Description:

The metabolic effects of atypical antipsychotics in children are well known, and carefully weighing the risk-benefit ratio of their use is a difficult ordeal for both parents and clinicians. The reality is that the use of these meds is necessary for some children, particularly those dealing with an autism spectrum disorder with serious behavioral problems. Risperidone is the most commonly used atypical for this purpose. To better understand its impact on weight and metabolic processes, researchers tracked multiple metabolic risk factors in autistic children ages 4–13.

As part of a larger 24-week randomized trial, 97 autistic children assigned to risperidone only or risperidone plus parent training were monitored for changes in appetite, weight, and markers associated with metabolic syndrome (waistline, glucose, lipids, hypertension). Children received twice-daily dosing of risperidone. Dosing was based on weight and ranged from 1.75 mg/day for children less than 20 kg/44 lbs and 3.5 mg/day for those heavier than 45 kg/99 lbs.

The results were striking. After 6 months of treatment, the children’s weight increased by an average of 5.4 kg/11.9 lbs, waist size increased by slightly more than 6 cm/2.4 inches, and the percentage of kids with a normal BMI (body mass index) decreased from 60.8% to 29.4%. A number of laboratory measures of health also worsened, including increases on glucose and liver enzymes. The number of kids with metabolic syndrome grew from 7 to 19 by 4 months. The effect of risperidone on weight was greatest for children who reported being hungrier during the first 8 weeks.

CCPR’s Take: While this study did not include a placebo group to act as a control, the dramatic metabolic effects of risperidone on children are well known from other research. The authors make specific suggestions about labs to monitor before and during treatment (see bulleted list below). Unfortunately, there are no suggestions about how to minimize the potential negative effects, nor do there appear to be any other interventions that are quite as effective for agitation in autism as atypical antipsychotics. Still, studies such as this one encourage us to try out as many alternatives as possible.

The authors of the article recommend measuring the following before starting children on atypical antipsychotics:

• Appetite-¹
• Weight-¹
• Waist circumference-¹
• Liver function-²
• Lipids-²
• Glucose-²

^1-Monitor early and regularly during treatment.

^2-Monitor periodically.