BNF for Children 2011-2012

BNFC 2011–2012 4.2.1 Antipsychotic drugs 177Indication and doseSchizophrenia and other psychoses, short-termadjunctive management of psychomotor agitation,excitement and violent or dangerouslyimpulsive behaviour (under specialist supervision). By mouthChild 12–18 years initially 5 mg twice daily,increased by 5 mg daily after 1 week, then atintervals of 3 days, according to responseShort-term adjunctive management of severeanxiety (under specialist supervision). By mouthChild 3–6 years up to 500 micrograms twice dailyChild 6–12 years up to 2 mg twice dailyChild 12–18 years 1–2 mg twice daily, increasedif necessary to 3 mg twice dailyAntiemetic section 4.6Trifluoperazine (Non-proprietary) ATablets, coated, trifluoperazine (as hydrochloride)1 mg, net price 112-tab pack = £7.22; 5 mg, 112-tabpack = £4.65. Label: 2Oral solution, trifluoperazine (as hydrochloride)5 mg/5 mL, net price 150-mL pack = £10.84. Label: 2Stelazine c (Goldshield) ATablets, blue, f/c, trifluoperazine (as hydrochloride)1 mg, net price 112-tab pack = £3.43; 5 mg, 112-tabpack = £4.89. Label: 2Syrup, sugar-free, yellow, trifluoperazine (as hydrochloride)1 mg/5 mL, net price 200-mL pack = £2.95.Label: 2Atypical antipsychotic drugsThe ‘atypical antipsychotic’ drugs amisulpride, aripiprazole,clozapine, olanzapine, quetiapine, and risperidonemay be better tolerated than other antipsychoticdrugs; extrapyramidal symptoms may be lessfrequent than with older antipsychotic drugs.Clozapine, olanzapine, and quetiapine cause little or noelevation of prolactin concentration; when changingfrom other antipsychotic drugs, a reduction in prolactinmay increase fertility.Clozapine is used for the treatment of schizophreniaonly in children unresponsive to, or intolerant of, conventionalantipsychotic drugs. It can cause agranulocytosisand its use is restricted to patients registeredwith a clozapine Patient Monitoring Service (see underClozapine).NICE guidanceAripiprazole for the treatment ofschizophrenia in people aged 15 to 17 years(January 2011)Aripiprazole is recommended as an option for thetreatment of schizophrenia in adolescents aged 15 to17 years who have not responded adequately to, orwho are intolerant of, risperidone, or for whomrisperidone is contra-indicated.Cautions and contra-indications While atypicalantipsychotic drugs have not generally been associatedwith clinically significant prolongation of the QT interval,they should be used with care if prescribed withother drugs that increase the QT interval. Atypical antipsychoticdrugs should be used with caution in childrenwith cardiovascular disease, or a history of epilepsy;interactions: Appendix 1 (antipsychotics).Skilled tasks Atypical antipsychotic drugs may affectperformance of skilled tasks (e.g. driving); effects ofalcohol are enhanced.Withdrawal Withdrawal of antipsychotic drugs afterlong-term therapy should always be gradual and closelymonitored to avoid the risk of acute withdrawal syndromesor rapid relapse.Side-effects Side-effects of the atypical antipsychoticdrugs include weight gain, dizziness, postural hypotension(especially during initial dose titration) whichmay be associated with syncope or reflex tachycardia insome children, extrapyramidal symptoms (usually mildand transient and which respond to dose reduction or toan antimuscarinic drug), and occasionally tardive dyskinesiaon long-term administration (discontinue drugon appearance of early signs); venous thromboembolismhas been reported. Hyperglycaemia and sometimesdiabetes can occur, particularly with clozapine, olanzapine,quetiapine, and risperidone; monitoring weightand plasma-glucose concentration may identify thedevelopment of hyperglycaemia. Neuroleptic malignantsyndrome has been reported rarely. Hypersalivationassociated with clozapine therapy can be treated withhyoscine hydrobromide (p. 198), provided that thepatient is not at particular risk from the additive antimuscarinicside-effects of hyoscine and clozapine.AMISULPRIDECautions see notes aboveContra-indications see notes above; phaeochromocytoma,prolactin-dependent tumoursRenal impairment halve dose if estimated glomerularfiltration rate 30–60 mL/minute/1.73 m 2 ; use onethirddose if estimated glomerular filtration rate 10–30 mL/minute/1.73 m 2 ; no information available ifestimated glomerular filtration rate less than 10 mL/minute/1.73 m 2Pregnancy avoidBreast-feeding avoid—no information availableSide-effects see notes above; also insomnia, anxiety,agitation, drowsiness, gastro-intestinal disorders suchas constipation, nausea, vomiting, and dry mouth;hyperprolactinaemia; occasionally bradycardia;rarely seizuresIndication and doseAcute psychotic episode (under specialist supervision). By mouthChild 15–18 years 200–400 mg twice dailyadjusted according to response; max. 1.2 g dailyPredominantly negative symptoms (under specialistsupervision). By mouthChild 15–18 years 50–300 mg daily4 Central nervous system