Children and Adolescents

✽ Approved for use in schizophrenia (ages 13 and older), mania/mixed episodes (ages 10 and older), and irritability associated with autism (ages 5–16)

✽ Risperidone is the most frequently used atypical antipsychotic in children and adolescents

• Clinical experience and early data suggest risperidone is safe and effective for behavioral disturbances in children and adolescents

• Children and adolescents using risperidone may need to be monitored more often than adults

Pregnancy

• Risk Category C [some animal studies show adverse effects; no controlled studies in humans]

• There is a risk of abnormal muscle movements and withdrawal symptoms in newborns whose mothers took an antipsychotic during the third trimester; symptoms may include agitation, abnormally increased or decreased muscle tone, tremor, sleepiness, severe difficulty breathing, and difficulty feeding

• Psychotic symptoms may worsen during pregnancy and some form of treatment may be necessary

• Early findings of infants exposed to risperidone in utero do not show adverse consequences

• Risperidone may be preferable to anticonvulsant mood stabilizers if treatment is required during pregnancy

• Effects of hyperprolactinemia on the fetus are unknown

Breast Feeding

• Some drug is found in mother’s breast milk

✽ Recommended either to discontinue drug or bottle feed

• Infants of women who choose to breast feed while on risperidone should be monitored for possible adverse effects

Risperidone: the art of psychopharmacology Potential Advantages

• Some cases of psychosis and bipolar disorder refractory to treatment with other antipsychotics

✽ Often a preferred treatment for dementia with aggressive features

✽ Often a preferred atypical antipsychotic for children with behavioral disturbances of multiple causations

✽ Noncompliant patients (long-acting injectable risperidone)

✽ Long-term outcomes may be enhanced when compliance is enhanced (long-acting injectable risperidone)

Potential Disadvantages

• Patients for whom elevated prolactin may not be desired (e.g., possibly pregnant patients; pubescent girls with amenorrhea; postmenopausal women with low estrogen who do not take estrogen replacement therapy)

Primary Target Symptoms

• Positive symptoms of psychosis

• Negative symptoms of psychosis

• Cognitive functioning

• Unstable mood (both depression and mania)

• Aggressive symptoms

Pearls

✽ Well accepted for treatment of behavioral symptoms in children and adolescents, but may have more sedation and weight gain in pediatric populations than in adult populations

✽ Well accepted for treatment of agitation and aggression in elderly demented patients

• Many anecdotal reports of utility in treatment-refractory cases and for positive symptoms of psychosis in disorders other than schizophrenia

• Hyperprolactinemia in women with low estrogen may accelerate osteoporosis

• Less weight gain than some antipsychotics, more than others

• Less sedation than some antipsychotics, more than others

• Increased risk of stroke may be most relevant in the elderly with atrial fibrillation

• May cause more motor side effects than some other atypical antipsychotics, especially when administered to patients with Parkinson’s disease or Lewy body dementia

• Patients with inadequate responses to atypical antipsychotics may benefit from determination of plasma drug levels and, if low, a dosage increase even beyond the usual prescribing limits

• Patients with inadequate responses to atypical antipsychotics may also benefit from a trial of augmentation with a conventional antipsychotic or switching to a conventional antipsychotic

• However, long-term polypharmacy with a combination of a conventional antipsychotic with an atypical antipsychotic may combine their side effects without clearly augmenting the efficacy of either

• For treatment-resistant patients, especially those with impulsivity, aggression, violence, and self-harm, long-term polypharmacy with 2 atypical antipsychotics or with 1 atypical antipsychotic and 1 conventional antipsychotic may be useful or even necessary while closely monitoring

• In such cases, it may be beneficial to combine 1 depot antipsychotic with 1 oral antipsychotic

• Although a frequent practice by some prescribers, adding 2 conventional antipsychotics together has little rationale and may reduce tolerability without clearly enhancing efficacy

THE ART OF SWITCHING