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COMPLICATED CASE HISTORIES Key Words: Risperidone, Conduct Disorder, Adolescence, Medication Noncompliance, Attention Deficit Hyperactivity Disorder
Long Acting Risperidone in an Adolescent with Conduct Disorder: A Case Report By Mustafa Deniz Tutkunkardas¸, Osman Abali ~ Adolescent conduct disorder (CD) is generally hard to manage clinically, as this population often refuses to take oral medications. Families and acquaintances of these adolescents usually suffer from extreme psychological, financial and social difficulties. Oral antipsychotics are the primary drugs of choice clinically, after behavioral treatments. Here we report a case with attention deficit hyperactivity disorder and conduct disorder who refuses to take any medications, was not eligible for behavioral treatments and was treated successfully with long acting risperidone. Psychopharmacology Bulletin. 2011;44(3):69–72.
ABSTRACT
INTRODUCTION Adolescent conduct disorder (CD) is generally hard to manage clinically, as this population often refuses to take oral medications. Families and acquaintances of these adolescents usually suffer from extreme psychological, financial and social difficulties. Thus, it is important to treat these adolescents and adapt them to society. Oral antipsychotics are the primary drugs of choice clinically.1 As no oral medication could be used in this case, a long acting parenteral atypical antipsychotic was selected after considering tolerability, side effect and response profile. Risperidone is the only atypical antipsychotic with long acting intramuscular form and this case report proposes the use of long acting intramuscular risperidone in management of non-treatment adherent adolescents with CD. Patient was clinically evaluated with DSM-IV criteria. Symptom remission and adverse events were identified clinically.
Drs. Tutkunkardas¸, MD, Abali, Assoc. Prof, MD, Child and Adolescent Psychiatry Department, Istanbul School of Medicine, Istanbul University, Istanbul, Turkey. To .. whom correspondence should be addressed: Dr. Mustafa Deniz Tutkunkardas¸, MD, Istanbul Universitesi, Istanbul Tip Fakultesi, Cocuk Psikiyatrisi Anabilim Dali, Capa, Istanbul, Turkey. Phone: +90 532 394 5084; Fax: +90 212 588 2426; E-mail: [email protected]
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CASE HISTORY T. is a 16 year-old boy who has been followed-up for 7 years with the initial complaints of boredom, school failure, overactivity and defiance. His initial psychiatric evaluation revealed that he had symptoms of hyperactivity since he was a toddler and inattention became a major problem in his first year in primary school, and he was found to be in the normal intelligence range with a verbal IQ of 96, performance IQ of 89 and a full IQ of 91. His laboratory workup and physical examination were nonsignificant. He was diagnosed with attention deficit hyperactivity disorder (ADHD) and prescribed methylphenidate. Short acting methylphendate was initiated at a dose of 10 mg/day TID and was titrated up to 25 mg/day TID. He showed good response to methylphenidate alone and his symptoms of inattention and hyperactivity regressed. SYMPTOMATOLOGY 70 Tutkunkardas¸, Abali
With the only problem being drug non-compliance, he was stable for nearly 4 years, during which he was switched to long acting methylphenidate 36 mg/day and was titrated up to 54 mg/day, after which his problems of defiance and conduct started to increase (3 years ago) and included fire-setting, stealing money, purposefully hurting other people, cursing at superiors and lying to superiors. DIAGNOSIS He received the additional diagnosis of conduct disorder. These additional symptoms were suspected to be a result of parental conflicts and friendship with defiant peers. Paternal conflicts were resolved with family guidance at a local counselor but his friendship with defiant peers could not be stopped. So 0.5 mg/day risperidone was added to his prescription of methylphenidate which was 54 mg/day long acting methylphenidate. As he was coming from a rural area, which took him many hours to reach our clinic and made it impossible both for him and his parents to attend to complementary behavioral treatment. Despite bimonthly dose increments of risperidone up to 2 mg/day he showed no major signs of improvement and eventually refused to use any medications including methylphenidate with the statement that drugs caused indigestion. TREATMENT As his symptoms of ADHD and CD became unbearable to surrounding people and posed a serious threat to acquaintances, and his
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family was unsuccessful in having him take his medications he was prescribed long acting risperidone 25 mg/15 days (lowest possible dose) and an anticholinergic agent (diphenhydramine) with an informed consent from his mother. His mother called the physicians office daily for signs of improvement and adverse events. Patient visits were appointed bimonthly, during which his laboratory workup and physical examination were repeated. After 15 days from his first injection, he showed no signs of improvement and expressed his feeling of discontent but yet rejected to take any oral medications including his anticholinergic medication. As he showed no signs of extrapyramidal syndrome, he was permitted not to use it. After 30–45 days from his first injection he started to show some signs of improvement as his aggressive, acting-out behaviors started to decline and the magnitude of his symptoms of conduct started to decrease, his relationship with other defiant peers decreased and eventually ended, and showed no signs of extrapyramidal syndrome. As he was still refusing to use oral medications methylphenidate could not be initiated. After 6 months from the initiation of long acting risperidone he agreed to take oral medications and displayed only relatively minor disruptive behaviors including cursing towards others and verbal threats. He no longer met the criteria for CD so he received the diagnoses of ADHD and oppositional defiant disorder (ODD). As he showed substantial improvement and agreed to take oral medications his injections were ceased and he was prescribed methylphenidate with oral risperidone. Oral risperidone was slowly tapered down. His symptoms neither deteriorated nor ameliorated and he was stable. After 2 years, from his first injection, he is still stable and on methylphenidate. Long acting risperidone was well tolerated in this adolescent with the only side effect being nearly 20% weight gain (initial body weight was 47 kg’s, ending body weight was 58 kg’s). As he was expected to gain 6 kg/year according to national norms it can be concluded that risperidone contributed approximately 5 kg, which he lost a year after discontinuing long acting risperidone. No extrapyramidal side effects were observed.
71 Tutkunkardas¸, Abali
DISCUSSION Low treatment-adherence is frequent in adolescence, especially in ADHD with comorbid CD/ODD.2 In severe situations, noncompliance to treatment causes incarcerations and severe psychosocial problems.3 Thus it is of utmost importance to deliver appropriate treatments to these difficult-to-control cases. It is hard to manage these P SYCHOPHARMACOLOGY B ULLETIN : Vol. 44 · No. 3
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72 Tutkunkardas, Abali
patients for the clinicians also, leading to frequent outpatient and emergency visits, and hospitalizations. Risperidone is the only atypical antipsychotic with long acting form, which makes it a suitable choice for patients with drug refusal. According to product information, the patient is told to keep taking oral risperidone during the first 3 weeks of long acting risperidone injections as slow metabolization of intramuscular risperidone delays the drug to reach effective plasma concentration. As drug refusal was the primary concern in this instance, the patient was directly prescribed long acting risperidone and its effects were first observed in the 4th week. Extrapyramidal syndrome is less frequent with long acting risperidone than with oral risperidone4 but the patient was prescribed an anticholinergic agent just in case. Because the patient refused to take any medications, he did not take it also, yet he did not show any signs of extrapyramidal syndrome. ADHD is most frequently comorbid with disruptive behavior disorders. CD is clinically hard to manage, and oral drug refusal complicates this disorder and contributes to its hard manageability. Atypical antipsychotics have long been shown to be effective in the treatment of disruptive disorders.5 Use of long acting intramuscular risperidone in adolescents has not been sufficiently studied, but wide safety profile of oral risperidone and good therapeutic response rates makes it a drug of choice especially in non-treatment-adherent cases. This text reports an adolescent with CD that was successfully treated with long acting risperidone, but case series and larger clinical trials are required to draw more accurate results. ✤ REFERENCES 1. 2. 3. 4. 5.
Findling RL. Atypical antipsychotic treatment of disruptive behavior disorders in children and adolescents. J Clin Psychiatry. 2008;69(4 Suppl.):9–14. Thiruchelvam D, Charach A, Schachar RJ. Moderators and mediators of long-term adherence to stimulant treatment in children with ADHD. J Am Acad Child Adolesc Psychiatry. 2001;40(8):922–928. Faigel HC, Sznajderman S, Tishby O, et al. Attention deficit disorder during adolescence: a review. J Adolesc Health. 1995;16(3):174–184. Emsley R, Oosthuizen P, Koen L, et al. Oral versus injectable antipsychotic treatment in early psychosis: post hoc comparison of two studies. Clin Ther. 2008;30(12):2378–2386. Pandina GJ, Aman MG, Findling RL. Risperidone in the management of disruptive behavior disorders. J Child Adolesc Psychopharmacology. 2006;16(4):379–392.
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COMPLICATED CASE HISTORIES Key Words: Risperidone, Conduct Disorder, Adolescence, Medication Noncompliance, Attention Deficit Hyperactivity Disorder
Long Acting Risperidone in an Adolescent with Conduct Disorder: A Case Report By Mustafa Deniz Tutkunkardas¸, Osman Abali ~ Adolescent conduct disorder (CD) is generally hard to manage clinically, as this population often refuses to take oral medications. Families and acquaintances of these adolescents usually suffer from extreme psychological, financial and social difficulties. Oral antipsychotics are the primary drugs of choice clinically, after behavioral treatments. Here we report a case with attention deficit hyperactivity disorder and conduct disorder who refuses to take any medications, was not eligible for behavioral treatments and was treated successfully with long acting risperidone. Psychopharmacology Bulletin. 2011;44(3):69–72.
ABSTRACT
INTRODUCTION Adolescent conduct disorder (CD) is generally hard to manage clinically, as this population often refuses to take oral medications. Families and acquaintances of these adolescents usually suffer from extreme psychological, financial and social difficulties. Thus, it is important to treat these adolescents and adapt them to society. Oral antipsychotics are the primary drugs of choice clinically.1 As no oral medication could be used in this case, a long acting parenteral atypical antipsychotic was selected after considering tolerability, side effect and response profile. Risperidone is the only atypical antipsychotic with long acting intramuscular form and this case report proposes the use of long acting intramuscular risperidone in management of non-treatment adherent adolescents with CD. Patient was clinically evaluated with DSM-IV criteria. Symptom remission and adverse events were identified clinically.
Drs. Tutkunkardas¸, MD, Abali, Assoc. Prof, MD, Child and Adolescent Psychiatry Department, Istanbul School of Medicine, Istanbul University, Istanbul, Turkey. To .. whom correspondence should be addressed: Dr. Mustafa Deniz Tutkunkardas¸, MD, Istanbul Universitesi, Istanbul Tip Fakultesi, Cocuk Psikiyatrisi Anabilim Dali, Capa, Istanbul, Turkey. Phone: +90 532 394 5084; Fax: +90 212 588 2426; E-mail: [email protected]
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CASE HISTORY T. is a 16 year-old boy who has been followed-up for 7 years with the initial complaints of boredom, school failure, overactivity and defiance. His initial psychiatric evaluation revealed that he had symptoms of hyperactivity since he was a toddler and inattention became a major problem in his first year in primary school, and he was found to be in the normal intelligence range with a verbal IQ of 96, performance IQ of 89 and a full IQ of 91. His laboratory workup and physical examination were nonsignificant. He was diagnosed with attention deficit hyperactivity disorder (ADHD) and prescribed methylphenidate. Short acting methylphendate was initiated at a dose of 10 mg/day TID and was titrated up to 25 mg/day TID. He showed good response to methylphenidate alone and his symptoms of inattention and hyperactivity regressed. SYMPTOMATOLOGY 70 Tutkunkardas¸, Abali
With the only problem being drug non-compliance, he was stable for nearly 4 years, during which he was switched to long acting methylphenidate 36 mg/day and was titrated up to 54 mg/day, after which his problems of defiance and conduct started to increase (3 years ago) and included fire-setting, stealing money, purposefully hurting other people, cursing at superiors and lying to superiors. DIAGNOSIS He received the additional diagnosis of conduct disorder. These additional symptoms were suspected to be a result of parental conflicts and friendship with defiant peers. Paternal conflicts were resolved with family guidance at a local counselor but his friendship with defiant peers could not be stopped. So 0.5 mg/day risperidone was added to his prescription of methylphenidate which was 54 mg/day long acting methylphenidate. As he was coming from a rural area, which took him many hours to reach our clinic and made it impossible both for him and his parents to attend to complementary behavioral treatment. Despite bimonthly dose increments of risperidone up to 2 mg/day he showed no major signs of improvement and eventually refused to use any medications including methylphenidate with the statement that drugs caused indigestion. TREATMENT As his symptoms of ADHD and CD became unbearable to surrounding people and posed a serious threat to acquaintances, and his
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family was unsuccessful in having him take his medications he was prescribed long acting risperidone 25 mg/15 days (lowest possible dose) and an anticholinergic agent (diphenhydramine) with an informed consent from his mother. His mother called the physicians office daily for signs of improvement and adverse events. Patient visits were appointed bimonthly, during which his laboratory workup and physical examination were repeated. After 15 days from his first injection, he showed no signs of improvement and expressed his feeling of discontent but yet rejected to take any oral medications including his anticholinergic medication. As he showed no signs of extrapyramidal syndrome, he was permitted not to use it. After 30–45 days from his first injection he started to show some signs of improvement as his aggressive, acting-out behaviors started to decline and the magnitude of his symptoms of conduct started to decrease, his relationship with other defiant peers decreased and eventually ended, and showed no signs of extrapyramidal syndrome. As he was still refusing to use oral medications methylphenidate could not be initiated. After 6 months from the initiation of long acting risperidone he agreed to take oral medications and displayed only relatively minor disruptive behaviors including cursing towards others and verbal threats. He no longer met the criteria for CD so he received the diagnoses of ADHD and oppositional defiant disorder (ODD). As he showed substantial improvement and agreed to take oral medications his injections were ceased and he was prescribed methylphenidate with oral risperidone. Oral risperidone was slowly tapered down. His symptoms neither deteriorated nor ameliorated and he was stable. After 2 years, from his first injection, he is still stable and on methylphenidate. Long acting risperidone was well tolerated in this adolescent with the only side effect being nearly 20% weight gain (initial body weight was 47 kg’s, ending body weight was 58 kg’s). As he was expected to gain 6 kg/year according to national norms it can be concluded that risperidone contributed approximately 5 kg, which he lost a year after discontinuing long acting risperidone. No extrapyramidal side effects were observed.
71 Tutkunkardas¸, Abali
DISCUSSION Low treatment-adherence is frequent in adolescence, especially in ADHD with comorbid CD/ODD.2 In severe situations, noncompliance to treatment causes incarcerations and severe psychosocial problems.3 Thus it is of utmost importance to deliver appropriate treatments to these difficult-to-control cases. It is hard to manage these P SYCHOPHARMACOLOGY B ULLETIN : Vol. 44 · No. 3
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patients for the clinicians also, leading to frequent outpatient and emergency visits, and hospitalizations. Risperidone is the only atypical antipsychotic with long acting form, which makes it a suitable choice for patients with drug refusal. According to product information, the patient is told to keep taking oral risperidone during the first 3 weeks of long acting risperidone injections as slow metabolization of intramuscular risperidone delays the drug to reach effective plasma concentration. As drug refusal was the primary concern in this instance, the patient was directly prescribed long acting risperidone and its effects were first observed in the 4th week. Extrapyramidal syndrome is less frequent with long acting risperidone than with oral risperidone4 but the patient was prescribed an anticholinergic agent just in case. Because the patient refused to take any medications, he did not take it also, yet he did not show any signs of extrapyramidal syndrome. ADHD is most frequently comorbid with disruptive behavior disorders. CD is clinically hard to manage, and oral drug refusal complicates this disorder and contributes to its hard manageability. Atypical antipsychotics have long been shown to be effective in the treatment of disruptive disorders.5 Use of long acting intramuscular risperidone in adolescents has not been sufficiently studied, but wide safety profile of oral risperidone and good therapeutic response rates makes it a drug of choice especially in non-treatment-adherent cases. This text reports an adolescent with CD that was successfully treated with long acting risperidone, but case series and larger clinical trials are required to draw more accurate results. ✤ REFERENCES 1. 2. 3. 4. 5.
Findling RL. Atypical antipsychotic treatment of disruptive behavior disorders in children and adolescents. J Clin Psychiatry. 2008;69(4 Suppl.):9–14. Thiruchelvam D, Charach A, Schachar RJ. Moderators and mediators of long-term adherence to stimulant treatment in children with ADHD. J Am Acad Child Adolesc Psychiatry. 2001;40(8):922–928. Faigel HC, Sznajderman S, Tishby O, et al. Attention deficit disorder during adolescence: a review. J Adolesc Health. 1995;16(3):174–184. Emsley R, Oosthuizen P, Koen L, et al. Oral versus injectable antipsychotic treatment in early psychosis: post hoc comparison of two studies. Clin Ther. 2008;30(12):2378–2386. Pandina GJ, Aman MG, Findling RL. Risperidone in the management of disruptive behavior disorders. J Child Adolesc Psychopharmacology. 2006;16(4):379–392.
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