Most Antipsychotic Prescriptions Issued Properly to Kids

Despite persistent concerns over inappropriate antipsychotic prescribing in children, a new study suggests the majority of prescriptions for the medications are issued appropriately.

In response to greater second-generation antipsychotic use seen among Medicaid-insured youth than their privately insured peers, 31 US states have implemented Medicaid prior authorization policies for these medications, and most of those apply to children younger than 7 years.¹

Such prior authorization is currently mandated in Vermont, where researchers recently delved into antipsychotic prescribing patterns for Medicaid-insured pediatric patients across the state.²

“Part of our concern is that these medicines may be getting pulled out too early in the treatment planning for things like oppositional behavior, ahead of things like behavioral therapy that could be tried first,” said lead study author David C. Rettew, MD, director of the Pediatric Psychiatry Clinic at the University of Vermont Medical Center, in a press release. “…I'm not anti-antipsychotics; I just want to make sure they’re used very carefully.”

Using Medicaid claims data, Dr. Rettew and his colleagues sent a prior authorization survey to prescribers of each antipsychotic agent issued to a Medicaid-insured child in Vermont between July and October 2012. After receiving 677 completed surveys from 147 prescribers, they referred to best practice guidelines from the American Academy of Child and Adolescent Psychiatry (AACAP) to assess the appropriateness of the antipsychotic prescriptions.

In nearly 92% of the cases, the antipsychotic prescription followed the AACAP’s clinical indication guidelines, which advise that children who have not been diagnosed with major mental illness but present with other behavioral problems receive antipsychotic medications only after other pharmacologic and nonpharmacologic therapies have been tried. Similarly, in compliance with those guidelines, antipsychotics were not prescribed for minor issues, such as temper tantrums.

Nevertheless, in half of the cases, prescribers deviated from the overall AACAP guidelines, mainly in failing to measure cholesterol and blood-glucose levels before and after a child began taking antipsychotics that are associated with increased risks for high cholesterol and diabetes.

“Current prescribing patterns of antipsychotic medications for children and adolescents follow best practice guidelines approximately one-half of the time, with nonadherence often related to lack of metabolic monitoring,” the authors concluded.

To help improve compliance with the AACAP guidelines, pharmacists should check in with pediatric patients taking antipsychotic medications about the recommended lab tests, Dr. Rettew told Pharmacy Times in an e-mail.

He also pointed out that pharmacists can help ensure a patient’s medication history is easily obtainable when he or she switches pharmacies or physicians.

“One thing we found from our study is that doctors often don't know what has been tried before, either related to therapy or other medications,” Dr. Rettew told Pharmacy Times. “Without knowing what’s been tried before, it’s tough knowing at what point antipsychotic medications should be considered.”

References

1.Schmid I, Burcu M, Zito M. Medicaid prior authorization policies for pediatric use of antipsychotic medications. JAMA. 2015;313(9):966.

2. Rettew DC, et al. Antipsychotic medication prescribing in children enrolled in Medicaid. Pediatrics. 2015;2014-2260.