Autism : Meds for Aggression - Abilify Vs. Risperdal- Which better ?

Описание: By Dr Panchajanya Paul
Best Medication for treating Aggression in Autism: Risperidone Vs. Aripiprazole?

When I get to see children with Autism, behavioral problems have become so worse that children cannot be managed safely at home and school. There is repeated shouting, yelling, cutting scratching, banging head, biting, punching destroying property. In those situations, I consider medications.

Although many medications are used to treat Autism, only two drugs- Abilify and Risperdal are extensively studied for their safety and efficacy in children with Autism. As a result, the federal drug administration (FDA) has approved them to treat the irritability associated with Autism in ages 6-17.

As a psychiatrist, when I see severe Autism with aggression, I generally choose either Abilify or Risperdal. Today, I will discuss the advantages and disadvantages of both, and when I choose one over another.

Risperidone, also called Risperdal, was the first drug studied in patients with Autism. It is a dopamine antagonist, works by blocking the dopamine receptors in the brain. It can be used at a lower dose of 0.25 mg to a maximum dose of 6 mg in children. It works great and can reduce symptoms of aggressive behavior in half of the patients.

Common side effects of Risperdal are sedation, fatigue, and best to be taken in the evening. Others are constipation, headache, and weight gain.

Risperdal also blocks the dopamine in the pituitary gland, which can elevate prolactin levels. High prolactin can cause breast enlargement (gynecomastia) and milk coming out of breast (galactorrhea). These rare side effects can happen and need careful monitoring. Long term use can cause abnormal involuntary movements, elevated blood sugar, and lipids.

The second medication approved by the FDA is Aripiprazole, also called Abilify. It partially blocks the dopamine activity in the brain, and hence produces fewer side effects. It does not cause sedation, and for many, activating, therefore preferably taken in the morning. Its starting dose is 2 mg, and the maximum is 30 mg. It can theoretically produce all the side effects of Risperdal, but since it allows some natural dopamine activity in the brain, it produces fewer serious side effects compared to Risperdal. Side effects nausea, vomiting, dizziness, activation, insomnia, and restlessness.

Now, if Abilify has fewer side effects, then why use Risperdal at all. Why can't all patients be treated with Abilify? It is because every patient is unique; some respond well to Risperdal and some to Abilify. Also, in my clinical experience, Risperdal is the more potent drug than Abilify- more effective in controlling symptoms, albeit with more side effects. And for bigger and stronger children with severe aggression, Risperdal works better. Secondly, if there are sleep problems, Risperdal is a better choice because of fo the sedation. However, once stable, I always try to switch patients from Risperdal to Abilify because of fewer side effects. Sometimes I am successful, but many times not, as some parents will swear that Risperdal is the only agent that will control the aggressive behaviors.

For both Risperdal and Abilify, the side effects are dose-dependent, and duration dependent. More extended use and higher doses will produce more side effects than shorter use and lower doses.
Routine blood monitoring is recommended for both to monitor blood levels of glucose, lipids, cell count, and prolactin. It is also essential to watch for weight gain, as children tend to gain more weight and are at increased risk for diabetes and hypertension.
Three additional points on medications :

1. There are many other medications used off label in children with Autism. Still, I always start with either Risperdal and Abilify as they are the most studied for efficacy and safety in children with Autism. Sometimes both fail, then I consider other medications.

2. Psychiatric medications can have serious side effects in the long term and require a regular visit to a psychiatrist and blood monitoring. Try behavioral therapy, and other modalities to address the problematic behavior first. Consider medications only when everything fails.

3. Since the medication does not address the core deficit of Autism, children do not need to stay on them forever. Once the children start doing better, and learn healthy coping skills, have a discussion with your doctor about lowering the dosage. When the children are on their lowest dosage, try a period without the medications. I have helped families with Autism, to reduce the number of drugs, and lower the dosages of the drugs. Some times, I have also guided them to wean off from all medications by combining other holistic approaches. But changing medications is very complicated and risky in children and should only be done under the strict supervision of a child psychiatrist.