FAR EASTER UNIVERSITY

INSTITUTE OF NURSING

EVIDENCE-BASED NURING CARE PROCESS

I. Clinical Question:
1. Is there a proportion of patients 5–18 years of age who received
anticholinergic therapy during the initial stages of antipsychotic treatment?
2. Is there a comparison between anticholinergic utilization across patients
receiving aripiprazole, risperidone, and quetiapine, SGAs previously
identified as the most commonly prescribed?
II. Citation:
Anticholinergic Use in Children and Adolescents after Initiation of
Antipsychotic Therapy. The use of antipsychotic medications in pediatric
patients has increased exponentially over the past decade. the second-
generation antipsychotics (SGAs) approved for use by the Food and Drug
Administration (FDA) in children and adolescents with irritability associated
with autism, bipolar mania, or schizophrenia. However, off-label use of
SGAs, including clozapine, paliperidone, quetiapine, and ziprasidone, is
common in pediatric patients with these diagnoses. First-generation
antipsychotics (FGAs) with indications for children and adolescents include
haloperidol, pimozide, and thioridazine. Patients with disruptive behavioral
disorders, mental retardation, tic disorders, as well as numerous other
childhood psychiatric conditions are also prescribed antipsychotic agents in
selected cases.[3] Long-term treatment with FGAs is associated with movement
disorders such as tardive dyskinesia and extrapyramidal symptoms (EPS).

III. Study Characteristics

1. Patients included (Population and sample):
 A total of 235 antipsychotic treatment courses were identified,
representing 195 patients. Of these, 179 treatment courses or 152
patients were included in the following analyses.

2. Interventions Compared
None.

3. Outcomes Monitored
a. Main Outcome Measured:
Children and adolescents 5–18 years of age were included for
study if they filled a prescription for any antipsychotic agent
between January 1, 2005, and September 1, 2008, at one of the
institutional pharmacies in Midwest academic medical center.

b. Main Results:
A total of 235 antipsychotic treatment courses were
identified. Of these, 152 patients met our inclusion criteria.
Anticholinergic utilization at any time during the first 30 days of
treatment was identified in 32 patients (21%), while EPS was
documented for 12 patients (8%). FGA or polypharmacy
(simultaneous use of ≥2 scheduled antipsychotic) use versus SGA
use (OR 18.98; 95% CI 4.74 to 75.95) was the primary characteristic
significantly associated with anticholinergic utilization within 30
days after initiation. Of the most commonly used SGAs, risperidone
was the drug with which anticholinergics were most frequently
prescribed (p = 0.03).

IV. Methodology/Design
1. Methodology Used:
A Retrospective Medical Record evaluation of patients seen at a
major Midwest academic center.
2. Design:
A cohort study with a duration of 44 months.
3. Setting:
United States of America.

4. Data Sources:
Irene Seunghyun Hong, PharmD
Drug Information Resident, Department of Pharmacy Practice, College of
Pharmacy, University of Illinois at Chicago and Jeffrey R Bishop,
PharmD MS BCPP
Assistant Professor, Department of Pharmacy Practice, College of
Pharmacy, University of Illinois at Chicago

5. Subject Selection:
a. Inclusion of Criteria:
Variables such as demographic information, psychiatric
diagnoses, antipsychotic doses, and prescribing of other
medications (psychotropic and nonpsychotropic) were evaluated
with regard to anticholinergic utilization. Children and
adolescents 5–18 years of age were included for study if they
filled a prescription for any antipsychotic agent between January
1, 2005, and September 1, 2008, at one of the institutional
pharmacies. The database for 5 outpatient pharmacies affiliated
with the hospital was accessed and a search was performed to
identify prescription fill history of patients meeting these criteria.
Patients who received at least 2 prescriptions of an antipsychotic,
spanning 60 days
b. Exclusion Criteria:
 Age >18 years, as well as presence of a non-antipsychotic
medication (such as metoclopramide or prochlorperazine) or
neurologic disorder known to elicit EPS. We excluded patients
who had documented utilization of an antipsychotic agent in the
previous 60 days as noted by either prescription records or
electronic medical records. Patients for whom there was not
enough information available in the medical records.

6. Has the original study been replicated?

No

V. Results of the Study

A total of 235 antipsychotic treatment courses were identified. Of these,
152 patients met our inclusion criteria. Anticholinergic utilization at any time
during the first 30 days of treatment was identified in 32 patients (21%), while
EPS was documented for 12 patients (8%). FGA or polypharmacy
(simultaneous use of ≥2 scheduled antipsychotic) use versus SGA use (OR
18.98; 95% CI 4.74 to 75.95) was the primary characteristic significantly
associated with anticholinergic utilization within 30 days after initiation. Of
the most commonly used SGAs, risperidone was the drug with which
anticholinergics were most frequently prescribed (p = 0.03).

VI. Author’s Conclusion

Conclusion: Anticholinergic prescribing exceeded the incidence of EPS,

as documented in the medical record (21% vs 8%), and differed across
individual medications and antipsychotic class. Utilization of FGAs or
polypharmacy was a key predictor of anticholinergic use. Prescriptions for
anticholinergics were documented in 21% of children and adolescents
receiving antipsychotics for various psychiatric disorders. Utilization was
 approximately 13% in patients prescribed only a SGA and was most common
in patients prescribed risperidone.

What over-all contribution to nursing knowledge does the study make?

Clinical observations suggest that anticholinergic medications are commonly

utilized in pediatric patients prescribed both FGAs and SGAs, despite the
theoretical decrease in incidence of EPS with SGAs. However, the scope of
anticholinergic use and differences across antipsychotic classes and individual
agents has not been extensively studied.

Recommendations:

More research I needed to identify Long-term utilization of

anticholinergics in combination with antipsychotic drugs and it side/adverse
effect. Additional larger scale studies are needed to determine unequivocally
the relationships between these variables and the risk for anticholinergic use. .
Although prophylactic use of anticholinergics may be a consideration for
patients prescribed agents with a relatively higher risk for inducing EPS (eg,
FGAs) or with a prior history of antipsychotic-induced EPS, there are no
guidelines defining the appropriateness of prophylactic utilization of
anticholinergics for patients prescribed SGAs. Regardless, the risk:benefit
ratio of treating young patients with these medications on top of antipsychotic
agents needs to be carefully considered.

VII. Applicability
1. Does the study provide a direct enough answer to your clinical
question in terms of type of patients, interventions and outcome?

Yes indeed. It was showed above those patients taking initial

treatment of antipsychotic medication (first-generation or second-
generation medicines) which has a side effect of movement disorders such
a tardive dyskinesia and Extrapyramidal Symptoms (EPS) taken with
anticholinergics such as benztropine, diphenhydramine, and trihexyphenidyl
to decrease the incidence of extrapyramidal symptoms. Also it was said that a
Second-Generation Antipsychotic specifically resperidone was most
commonly prescribed in patients in combine with anticholinergic drugs.