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Lyu N, Rowan PJ, Abughosh S, Varisco TJ, Lin Y, Chen H. Trajectories and Predictors for the Development of Clinically Significant Weight Gain in Children and Adolescents Prescribed Second-Generation Antipsychotics. J Child Adolesc Psychopharmacol 2024; 34:201-209. [PMID: 38407930 DOI: 10.1089/cap.2023.0071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/27/2024]
Abstract
Background: As many as 60% of pediatric patients taking second-generation antipsychotics (SGA) experience weight gain (antipsychotic-induced weight gain). However, the subgroup that experienced substantial weight increase was poorly understood. This study aimed to identify the development and predictors of clinically significant weight gain (CSWG) among pediatric SGA recipients. Methods: A retrospective analysis of the 2016 to 2021 IQVIA Ambulatory EMR-US database was conducted. The study cohort comprised SGA-naive patients ages 5 to 19, continuously prescribed SGA for ≥90 days. CSWG was defined as a weight gain in BMI z-score >0.5. The development of CSWG was described using the group-based trajectory model approach, and multinomial logistic regression analysis was conducted to examine the risk factors associated with the CSWG trajectories. Results: Of the 16,262 SGA recipients who met the inclusion criteria, 4 distinctive CSWG trajectories were identified: (1) Rapid (14.6%), (2) Gradual (12.6%), (3) Transit (7%), and (4) no CSWG (65.8%). Factors associated with a higher likelihood of having rapid or gradual CSWG versus nonsignificant weight gain were being younger (OR [95% CI] = 12-17 vs. 5-11, Rapid, 0.727 [0.655-0.806]; Gradual, 0.776 [0.668-0.903]), male (Rapid, 1.131 [1.021-1.253]), non-Hispanic White (Black vs. White: Rapid, 0.833 [0.709-0.98]), with lower baseline BMI z-score (Rapid, 0.376 [0.361-0.392]; Gradual, 0.449 [0.424-0.476]), and receiving olanzapine as the initial SGA (Rapid, 1.38 [1.093-1.74]). The Area under the Receiver operating characteristic (ROC) Curve for the comparison of rapid and gradual CSWG with no CSWG trajectory were 0.83 and 0.80, respectively. Conclusions: SGA recipients experienced four distinctive CSWG trajectories (Rapid, Gradual, Transient, and No CSWG). The risk of CSWG could be predicted using patient characteristics at the SGA initiation. This insight highlights the importance of personalized monitoring and timely intervention strategies for at-risk individuals who experienced persistent CSWG in real practice.
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Affiliation(s)
- Ning Lyu
- Department of Pharmaceutical Health Outcomes and Policy, College of Pharmacy, University of Houston, Houston, Texas, USA
| | - Paul J Rowan
- School of Public Health, The University of Texas at Houston, Houston, Texas, USA
| | - Susan Abughosh
- Department of Pharmaceutical Health Outcomes and Policy, College of Pharmacy, University of Houston, Houston, Texas, USA
| | - Tyler J Varisco
- Department of Pharmaceutical Health Outcomes and Policy, College of Pharmacy, University of Houston, Houston, Texas, USA
| | - Ying Lin
- College of Engineering, University of Houston, Houston, Texas, USA
| | - Hua Chen
- Department of Pharmaceutical Health Outcomes and Policy, College of Pharmacy, University of Houston, Houston, Texas, USA
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Lohr WD, Jawad K, Feygin Y, Le J, Creel L, Pasquenza N, Williams PG, Jones VF, Myers J, Davis DW. Antipsychotic Medications for Low-Income Preschoolers: Long Duration and Psychotropic Medication Polypharmacy. Psychiatr Serv 2022; 73:510-517. [PMID: 34470507 DOI: 10.1176/appi.ps.202000673] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVE This study aimed to evaluate prescribing patterns of antipsychotic medication and factors that predict duration of use among low-income, preschool-age children. METHODS State Medicaid claims from 2012 to 2017 were used to identify antipsychotic medication use for children <6 years old. ICD-9 and ICD-10 codes were used to describe child diagnoses. Descriptive and multivariable analyses were used to determine patterns of antipsychotic medication use and factors that predicted duration of use. RESULTS In 2012, 316 children <6 years of age started an antipsychotic medication in a southeastern state. Most were non-Hispanic White (N=202, 64%) and boys (N=231, 73%). Diagnoses included attention-deficit hyperactivity disorder (N=288, 91%), neurodevelopmental disorders (N=208, 66%), anxiety and trauma-related diagnoses (N=202, 64%), and autism spectrum disorders (ASDs) (N=137, 43%). The mean±SD duration of exposure to antipsychotic medication for children in the cohort was 2.6±1.7 years, but 86 children (27%) had >4 years of exposure. Almost one-third (N=97, 31%) received polypharmacy of four or more medication classes, and 42% (N=131) received metabolic screening. Being male, being in foster care, and having a diagnosis of ASD or disruptive mood dysregulation disorder were significantly associated with duration of use of antipsychotic medications; race-ethnicity was not significantly associated with duration of use. Emergency department visits (N=277, 88%) and inpatient hospitalizations (N=107, 34%) were observed during the study period. CONCLUSIONS Many preschoolers received antipsychotic medications for substantial periods. Further research is needed to identify evidence-based practices to reduce medication use and improve outcomes.
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Affiliation(s)
- W David Lohr
- Department of Pediatrics, University of Louisville School of Medicine, Louisville, Kentucky (Lohr, Jawad, Feygin, Le, Pasquenza, Williams, Jones, Myers, Davis); Department of Health Management and System Sciences, University of Louisville School of Public Health and Information Science, Louisville, Kentucky (Creel)
| | - Kahir Jawad
- Department of Pediatrics, University of Louisville School of Medicine, Louisville, Kentucky (Lohr, Jawad, Feygin, Le, Pasquenza, Williams, Jones, Myers, Davis); Department of Health Management and System Sciences, University of Louisville School of Public Health and Information Science, Louisville, Kentucky (Creel)
| | - Yana Feygin
- Department of Pediatrics, University of Louisville School of Medicine, Louisville, Kentucky (Lohr, Jawad, Feygin, Le, Pasquenza, Williams, Jones, Myers, Davis); Department of Health Management and System Sciences, University of Louisville School of Public Health and Information Science, Louisville, Kentucky (Creel)
| | - Jennifer Le
- Department of Pediatrics, University of Louisville School of Medicine, Louisville, Kentucky (Lohr, Jawad, Feygin, Le, Pasquenza, Williams, Jones, Myers, Davis); Department of Health Management and System Sciences, University of Louisville School of Public Health and Information Science, Louisville, Kentucky (Creel)
| | - Liza Creel
- Department of Pediatrics, University of Louisville School of Medicine, Louisville, Kentucky (Lohr, Jawad, Feygin, Le, Pasquenza, Williams, Jones, Myers, Davis); Department of Health Management and System Sciences, University of Louisville School of Public Health and Information Science, Louisville, Kentucky (Creel)
| | - Natalie Pasquenza
- Department of Pediatrics, University of Louisville School of Medicine, Louisville, Kentucky (Lohr, Jawad, Feygin, Le, Pasquenza, Williams, Jones, Myers, Davis); Department of Health Management and System Sciences, University of Louisville School of Public Health and Information Science, Louisville, Kentucky (Creel)
| | - P Gail Williams
- Department of Pediatrics, University of Louisville School of Medicine, Louisville, Kentucky (Lohr, Jawad, Feygin, Le, Pasquenza, Williams, Jones, Myers, Davis); Department of Health Management and System Sciences, University of Louisville School of Public Health and Information Science, Louisville, Kentucky (Creel)
| | - V Faye Jones
- Department of Pediatrics, University of Louisville School of Medicine, Louisville, Kentucky (Lohr, Jawad, Feygin, Le, Pasquenza, Williams, Jones, Myers, Davis); Department of Health Management and System Sciences, University of Louisville School of Public Health and Information Science, Louisville, Kentucky (Creel)
| | - John Myers
- Department of Pediatrics, University of Louisville School of Medicine, Louisville, Kentucky (Lohr, Jawad, Feygin, Le, Pasquenza, Williams, Jones, Myers, Davis); Department of Health Management and System Sciences, University of Louisville School of Public Health and Information Science, Louisville, Kentucky (Creel)
| | - Deborah Winders Davis
- Department of Pediatrics, University of Louisville School of Medicine, Louisville, Kentucky (Lohr, Jawad, Feygin, Le, Pasquenza, Williams, Jones, Myers, Davis); Department of Health Management and System Sciences, University of Louisville School of Public Health and Information Science, Louisville, Kentucky (Creel)
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Melamed OC, LaChance LR, O'Neill BG, Rodak T, Taylor VH. Interventions to Improve Metabolic Risk Screening Among Children and Adolescents on Antipsychotic Medication: A Systematic Review. J Child Adolesc Psychopharmacol 2021; 31:63-72. [PMID: 33512274 DOI: 10.1089/cap.2020.0115] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Objective: Antipsychotic use among youth is common and is associated with metabolic side effects such as weight gain. Guidelines recommend periodic screening of metabolic measures in youth prescribed antipsychotics; however, a guideline-to-practice gap exists. We systematically reviewed the literature to synthesize the knowledge from interventions that aim to improve antipsychotic metabolic screening. We described the interventions' effect on screening rates, the strategies used for improvement, and study quality. Methods: We conducted a systematic review of studies that attempted to improve antipsychotic metabolic risk screening practices among pediatric populations published between 2004 and August 2019. We included studies with an improvement intervention that compared screening rates before and after the intervention. We extracted data about study characteristics, screening rates in pre- and postintervention groups, strategies used to influence screening practices, and assessed studies' risk of bias. This review was prospectively registered with PROSPERO #CRD42018088241. Results: We identified six studies that demonstrated modest improvements in median metabolic screening rates for waist circumference (0%-16%), glucose (9%-39%), and lipids (11%-37%). Median postintervention screening rates were higher for weight and blood pressure (84% and 72.5%) compared with glucose and lipids (39% and 37%). Interventions used a variety of improvement strategies to address patient-, provider-, and organization-level barriers for screening, including increasing patient and provider knowledge regarding antipsychotic side effects, fostering social clinical environments that promote screening, and organizational commitment for screening antipsychotic-treated youth. All interventions were deemed at high risk of bias due to uncontrolled design and lack of adjustment for confounders. Conclusions: Included studies reported partial success in improving antipsychotic screening rates but were of poor methodological quality. Common improvement strategies may affect provider behavior to conduct metabolic screening, but these need to be tailored to local resources and organization structure. Future studies need to use rigorous methodology and theory-informed improvement strategies aligned with organizational actions to prioritize safe and judicious practice of antipsychotics among pediatric populations.
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Affiliation(s)
- Osnat C Melamed
- Centre for Addiction and Mental Health, Toronto, Ontario, Canada.,Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Laura R LaChance
- St. Mary's Hospital, Montreal, Quebec, Canada.,Department of Psychiatry, McGill University, Montreal, Quebec, Canada
| | - Braden G O'Neill
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada.,North York General Hospital, Toronto, Ontario, Canada
| | - Terri Rodak
- Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - Valerie H Taylor
- Department of Psychiatry, University of Calgary, Calgary, Alberta, Canada
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Guideline Adherence of Monitoring Antipsychotic Use for Nonpsychotic Indications in Children and Adolescents: A Patient Record Review. J Clin Psychopharmacol 2021; 41:13-18. [PMID: 33347017 PMCID: PMC7752226 DOI: 10.1097/jcp.0000000000001322] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND Antipsychotics are frequently prescribed to children and adolescents for nonpsychotic indications. Guidelines recommend regularly assessing treatment response and adverse effects and the ongoing need for their use. We aimed to assess adherence to recommendations of available guidelines regarding monitoring antipsychotic use and to test the influence of children's age, sex, intelligence quotient, and diagnosis on adherence. METHODS We reviewed 426 medical records from 26 centers within 3 large Dutch child and adolescent psychiatry organizations, excluding children with schizophrenia, psychosis, mania, or an intelligence quotient below 70. We investigated whether there was regular assessment of treatment response, adverse events (physical and laboratory), and at least annual discussion of the need of continued use. RESULTS On average, treatment response was assessed in 69.3% of the recommended treatment periods, height in 25.6%, weight in 30.6%, blood pressure in 20.6%, evaluation of adverse events in 19.4%, and cardiometabolic measures in 13.7%; discontinuation and/or continued need was discussed at least annually in 36.2%. Extrapyramidal and prolactin-related adverse effects, waist circumference, glucose, and lipids were rarely investigated. Higher age was associated with lower rates of assessment of treatment response. Most antipsychotics were prescribed long-term. In those children with sufficient documentation of the course of treatment, 57.7% was still using an antipsychotic 3 years after initiation. CONCLUSIONS Our findings indicate insufficient adherence to guideline recommendations for monitoring antipsychotic use in children and adolescents, as well as long duration of use in the majority of children. Especially, older children are at higher risk of receiving suboptimal care.
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Kelleher KJ, Rubin D, Hoagwood K. Policy and Practice Innovations to Improve Prescribing of Psychoactive Medications for Children. Psychiatr Serv 2020; 71:706-712. [PMID: 32188362 DOI: 10.1176/appi.ps.201900417] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Psychoactive medications are the most expensive and fastest-growing class of pharmaceutical agents for children. The cost, side effects, and unprecedented growth rate at which these drugs are prescribed have raised alarms from health care clinicians, patient advocates, and agencies about the appropriateness of how these drugs are distributed to parents and their children. This article examines current prescribing of three classes of psychoactive drugs-stimulants, antidepressants, and antipsychotics-and efforts to improve pediatric prescribing of these agents. Federal policy efforts to curb questionable prescribing of psychoactive medications to children have focused particularly on oversight of antipsychotic use among foster care children. The article reviews system-level interventions, including delivery system enhancements, which increase availability of alternatives to medication treatments, employ electronic medical record reminders, and increase cross-sector care coordination; clinician prescribing enhancements, which disseminate best-practice guidelines, create quality and learning collaboratives, and offer "second opinion" psychiatric consultations; and prescriber monitoring programs, which include retrospective review and prospective monitoring of physicians' prescribing to identify patterns suggestive of inappropriate prescribing. Potential interventions to deter inappropriate pediatric prescribing are briefly described, such as transparency in drug prices and incentives among insurers, public agencies, and pharmacy benefit managers; value-based purchasing, specifically value-based payment for medications; and preventive interventions, such as parent training.
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Affiliation(s)
- Kelly J Kelleher
- Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio (Kelleher); PolicyLab at Children's Hospital of Philadelphia, Philadelphia (Rubin); Department of Pediatrics, New York University Langone Health, New York (Hoagwood)
| | - David Rubin
- Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio (Kelleher); PolicyLab at Children's Hospital of Philadelphia, Philadelphia (Rubin); Department of Pediatrics, New York University Langone Health, New York (Hoagwood)
| | - Kimberly Hoagwood
- Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio (Kelleher); PolicyLab at Children's Hospital of Philadelphia, Philadelphia (Rubin); Department of Pediatrics, New York University Langone Health, New York (Hoagwood)
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Hayden JD, Horter L, Parsons T, Ruble M, Townsend S, Klein CC, Duran RP, Welge JA, Crystal S, Patel NC, Correll CU, DelBello MP. Metabolic Monitoring Rates of Youth Treated with Second-Generation Antipsychotics in Usual Care: Results of a Large US National Commercial Health Plan. J Child Adolesc Psychopharmacol 2020; 30:119-122. [PMID: 31851522 DOI: 10.1089/cap.2019.0087] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Objectives: To examine metabolic monitoring rates in commercially insured children and adolescents treated with a second-generation antipsychotic (SGA) during calendar years (CYs) 2016 and 2017. Methods: In this retrospective study, data were collected from a large national commercial health plan for the period covering January 1, 2016 to December 31, 2017. Commercially insured children and adolescents, aged 8-19 years with ≥2 SGA prescription claims during the CY, were identified for the CY2016 and CY2017 cohorts. The primary outcome of interest was the percentage of subjects with any glucose or lipid metabolism parameter monitoring. Other calculated metabolic testing rates included glucose, hemoglobin A1c (HbA1c), low-density lipoprotein cholesterol (LDL-C), other cholesterol (including triglycerides), and combined glucose and lipid metabolism testing (≥1 test for blood glucose or HbA1c and ≥1 test for LDL-C or other cholesterol). Results: In CY2016 and CY2017, 1502 and 1239 subjects, respectively, were identified for this study. The most common psychiatric diagnoses in CY2016 and CY2017 were major depressive disorder (57.1%, 56.5%, respectively), anxiety disorders (42.9%, 47.5%), attention-deficit/hyperactivity disorder (41.6%, 45.8%), and bipolar disorder (24.1%, 25.9%). The rate of any metabolic testing was 53.5% in CY2016 and 51.3% in CY2017. Glucose testing (50.3%, 46.9%, respectively) was most common in both CYs, followed by LDL-C testing (31.2%, 28.5%). Rates of combined glucose and lipid metabolism testing were 30.7% in CY2016 and 26.9% in CY2017. Conclusions: Given the known potential for adverse cardiometabolic effects, rates of metabolic monitoring associated with SGA use in children and adolescents urgently need to be improved. There is a critical need for understanding barriers to routine monitoring, particularly of lipids, and developing interventions to enhance metabolic monitoring.
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Affiliation(s)
| | - Libby Horter
- Humana Healthcare Research, Inc., Louisville, Kentucky
| | | | | | | | - Christina C Klein
- Department of Psychiatry and Behavioral Neuroscience, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Rodrigo Patino Duran
- Department of Psychiatry and Behavioral Neuroscience, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Jeffrey A Welge
- Department of Psychiatry and Behavioral Neuroscience, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Stephen Crystal
- Center for Health Services Research, Institute for Health, Rutgers University, New Brunswick, New Jersey
| | - Nick C Patel
- Humana Healthcare Research, Inc., Louisville, Kentucky
| | - Christoph U Correll
- Department of Psychiatry, The Zucker Hillside Hospital, Northwell Health, Glen Oaks, New York.,Department of Psychiatry and Molecular Medicine, Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York.,The Feinstein Institute for Medical Research, Manhasset, New York.,Department of Child and Adolescent Psychiatry, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Melissa P DelBello
- Department of Psychiatry and Behavioral Neuroscience, College of Medicine, University of Cincinnati, Cincinnati, Ohio
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