Side Effect Monitoring of Children with ASD Prescribed Second Generation Antipsychotics (SGAs)

Background:  Psychotropic medications, particularly SGAs, are prescribed frequently to children with autism spectrum disorders (ASD), with two (Risperidone and Aripiprazole) being FDA approved.  Risks of metabolic, neurologic, and cardiac side effects appear to be increased with young age, autism, intellectual disability, polypharmacy, and longer treatment duration.  Although a consensus conference suggested metabolic monitoring standards, rates of monitoring are low and guidelines for cardiac and neurologic monitoring have not been established.   

Objectives: This study investigates the monitoring practices of clinicians prescribing SGAs to children with ASD, compares metabolic monitoring practices with recommended standards, and describes cardiac and neurologic monitoring practices. 

Methods:

Fifty two clinicians from the 14 Autism Treatment Network (ATN) sites were asked to complete an online survey on SGA prescribing and monitoring.  Metabolic monitoring practices were compared to 2004 consensus conference recommendations:  1) Baseline personal/family history review, BMI, blood pressure, serum glucose and lipids, 2) quarterly BMI monitoring, 3) yearly glucose and BP, and 4) lipids every 5 years.  Because no standard of care exists for monitoring of cardiac or neurologic risks, current clinician practices were described.

Results:  

Responses were received from 31 clinicians, 23 of whom prescribe SGAs, including child neurologists, developmental pediatricians, nurse practitioners, and child psychiatrists.  Metabolic monitoring:  of those who prescribe SGAs, 70% obtain personal and family history to assess metabolic risks prior to treatment, 74% assess baseline growth parameters (Ht/ Wt/BMI) and 70% monitor them at least quarterly during treatment.  Glucose is measured by 26% and lipids by 30% at baseline, while 61% monitor glucose at least annually and 64% monitor lipids at least every 5 years, with most monitoring yearly or biannually.  Cardiac monitoring:  Personal/family history for cardiac risk factors is assessed by 70% at baseline; blood pressure is checked by 65% at baseline and by 65% at least annually.  Neurologic monitoring: At baseline, 65% perform a neurologic exam and 39% perform a standardized movement disorder evaluation.  During treatment, 65% perform/order a neurologic exam quarterly and 48% perform a movement exam monthly to semi-annually. Lastly, many clinicians routinely order additional tests prior to or during treatment, including ECG [9%], CBC [26%], HgA1C [17%], serum insulin [13%], LFT [39%], and prolactin level [9%].  Additional data from clinics not affiliated with this network will be presented.

Conclusions:  

In this initial study, metabolic monitoring rates were higher than has been reported in other studies.  This may be a function of quality improvement in the ATN.  More clinicians monitored regularly for metabolic and cardiac side effects than for neurologic side effects.    Recommendations for monitoring of neurologic and cardiac side effects in pediatric populations are needed, as are studies documenting efficacy of the current metabolic monitoring recommendations in children with ASD. 

Support from ATN-CRT-07-02 (Autism Speaks) and UA3MC11054 (MCHB).