Antipsychotic Medications, Diabetes, and Your Kids: What to Know

With John W. Newcomer, MD, and Marc De Hert, MD, PhD

Antipsychotic medicines such as Abilify, Risperdal, and Zyprexa, which are often given to children with serious behavioral problems or attention-deficit/hyperactivity disorder (ADHD), can lead to weight gain and decreased insulin sensitivity, raising the risk of diabetes, as experts know.

Now, using more sophisticated means to measure side effects, researchers provide more compelling data about giving any medication that is known to prompt weight gain to a child or teen who is at risk for diabetes.1

Certain psychiatric medications that can cause weight gain should be avoided in children with diabetes.

"Using gold standard measurements, we found that antipsychotic treatment increases not only whole body fat but also abdominal fat," says study leader John W. Newcomer, MD, professor of integrated medical science at Florida Atlantic University in Boca Raton, and adjunct professor of psychiatry at Washington University School of Medicine in St. Louis, Missouri. This is important since abdominal fat is strongly linked to increased risk of heart disease and diabetes. He also confirmed, using more sophisticated measured than those in previous studies by others, that the drugs decrease insulin sensitivity.2,3

The findings,published in JAMA Psychiatry, point to the need to more closely monitor youth on these medications, Dr. Newcomer tells EndocrineWeb, and offers greater urgency to consider whether nonmedical treatments, such as behavioral therapy, might be a workable alternative, particularly in children at clear risk for diabetes. 

Looking at Long-Term Consequences of Treatment in Children 

From 2006 through 2010, Dr. Newcomer and his team studied 144 youth, ages 6 to 18 years old, who had ADHD or disruptive behaviors.1 The behavioral characteristics, often including aggression, were sometimes deemed serious enough, for instance, to cause the child to be suspended from school. These youth had been prescribed oral olanzapine (Zyprexa), risperidone (Risperdal), or aripiprazole (Abilify).

Over the 12-week study,1 the researchers tracked changes in percent body fat and insulin sensitivity in muscles, abdominal fat, and blood measures. They found—the less insulin sensitivity, the more insulin a child needed to achieve good glucose control.

While previous studies looked at such measures as body weight (body mass index, BMI), Dr. Newcomer relied on more direct measures of body fat using dual-energy X-ray absorptiometry (DXA), and abdominal magnetic resonance imaging (MRI) as well as sophisticated measures to check on the patients level of insulin sensitivity.

In this study, the dosages of psych medication given were lower than what is usually prescribed to treat psychosis.1 For risperidone, only 1 milligram (mg) was given; for olanzapine, 6.3 mg; and, for aripiprazole, the dose was 6 mg.

These medications typically are prescribed for serious mental health conditions such as bipolar disorder and schizophrenia but are also used ''off-label" for behavioral issues. In off-label use, a doctor may choose to prescribe a medication for a use not specifically approved in children because based on clinical experience, he or she believes it will be useful for the condition. The practice is common and legal.

What Are the Concerns that Come with Psych Medications for Children?

The researchers confirmed that behavior improved for most children.1 This was supported by a 43% drop in school suspensions, a common problem among these youth. While this was good news, these same children experienced an increase in body fat of 1.18% with risperidone, 1.66% with aripiprazole and 4.12% for olanzapine.1

While 13% of the youth were overweight at the start, 21% of the children qualified as overweight after just three months on the low-dose medication. Even worse, 17% of the children started the study with obesity, which rose to 1 in 4 children at the end. This should cause parents to hesitate as obesity is the number one risk for increasing diabetes and well as heart disease.2,3

Not only did overall (subcutaneous) fat increase, so too did abdominal fat, with the greatest increases in subcutaneous fat occurring in the youth who were taking olanzapine.

The package labeling does warn of potential side effects from these psych medications. For instance, the label for Zyprexa says that weight gain and other side effects are more common in young patients and that they may want to consider other medications.

Reconsidering the Pros and Cons of Psych Meds Given the Increased Risk of Diabetes

Parents should be aware of these findings when discussing antipsychotic therapy for their children, says Marc De Hert, PhD, MD, a psychiatrist at Katholieke Universiteit Leuven in Belgium. He wrote an editorial that was published alongside the study. This is even more urgent when the child is already overweight or has obesity.

"Metabolic side effects (such as decreased insulin sensitivity and weight gain) are real concerns in antipsychotic use, or should be a concern," he tells EndocrineWeb. "These are more pronounced in first-time users and young people. This study, with state-of-the-art and gold standard measurement techniques, confirm and highlight the problem [facing children at risk for] non-psychotic disorders."5

While experts have long recommended close monitoring, Dr. De Hert says that that advice is often not followed. Parents should ask their children's doctor to explain about why they think the drug should be used, they should push for a more weight-neutral alternative, or non-drug alternative, and at least should insist on close weight monitoring.

He also suggested that doctors who prescribe these medications for behavioral issues should screen youth before starting them on a new medication to determine those at high risk, such as those with a family history of diabetes. Other measures to modify risk for undesirable weight gain and diabetes that parents should be aware of include:

  •  Monitoring a child's weight status and waist circumference.
  • Checking blood sugar, including a baseline level before starting a medication and then at least at the three-month mark.
  • Choose a medicine with a low to moderate risk profile for weight gain. According to the Newcomer study, that means avoiding olanzapine, Dr. De Hert says.
  • Ask the doctor if the lowest effective dose is being prescribed, and for the shortest time period. Sometimes a medication helps a child’s receptiveness to therapy. Once the therapy seems beneficial, it is worth a discussion about discontinuing the medication sooner than later.

Parents Are Urged to Consider the Long-Term Impact on Their Children

Dr. Newcomer suggests that parents take his study results to their child's physician and say: "I want to hash this out."

Parents might also consider asking about alternative behavioral therapies, says Dr. Newcomer. While he knows of no head-to-head comparisons of the medications versus behavioral therapy, he believes other options are worth exploring except in the case of the most severe behavioral problems.

This is important given the known complications that come with obesity and diabetes, such as cardiovascular disease, kidney disease, loss of vision (retinopathy), and nerve damage (neuropathy). Parents should also be aware that all the medications used in this study were linked with the changes in body fat and insulin sensitivity, he says, and the findings makes it clear that olanzapine carries the highest risk for children.

The decision, he adds, is not easy. Many of the youth he followed had treatment-resistant ADHD. And many of them were in trouble for aggressive behavior such as hitting people, he says.

"We met some very wonderful parents, struggling to find the best thing to help their child," he tells EndocrineWeb. "We get it that there are times when there is no other choice [but to give their child an antipsychotic medication]," he says. However, he cautions: "Think very carefully at the front end to see if there is something else [to try first].''

Neither of the doctors has any financial conflicts related to this study.

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