REVIEW OF: Yip L et al,  J Child Adolesc Psychopharmacol 2020;30(9):534–541

Acute agitation and aggression can lead to injury in the pediatric emergency department setting. Unfortunately, efficacy data for pharmacologic treatments are sparse.

Most clinicians choose first-generation antipsychotics (FGA) over second-generation antipsychotics (SGA) for acute agitation, despite FGAs’ higher adverse effect profile, due to lack of consensus on treatment with newer agents (Gerson R et al, West J Emerg Med 2019;20(2):409–418). But theoretically SGAs may be safer, and this study offers a start by comparing quetiapine with FGAs for youths with agitation.

The study was a single-center retrospective chart review of 69 patients with a median age of 15 years who presented to an emergency department with agitation and aggression. Of these, 32 were treated with quetiapine. The authors extracted weight-based dosages, the proportion of patients responsive to treatment within one hour of oral administration, and adverse effects from the patients’ charts.

The median weights of study participants ranged from 54 to 64 kg. Mean first doses were 0.54, 0.07, 0.19, and 0.53 mg/kg for quetiapine, haloperidol, loxapine, and chlorpromazine, respectively. Fifty-three percent of patients in the quetiapine group responded within the first hour, compared to 30%–50% of the FGA groups.

Side effects included extrapyramidal symptoms (EPS), headache, and nausea. Researchers observed no EPS in those taking quetiapine, whereas both parkinsonism and akathisia were reported in each FGA group. Headache was the only reported side effect in the quetiapine group.

Limitations of this study include the small sample size, which gives this study less power to detect positive effects as well as side effects. Also, because the study was a retrospective convenience sampling of available charts, its findings may lack generalizability.

CCPR’s Take:
While this study suggests that quetiapine carries a lower side effect risk than FGAs and may be more reliably effective in managing acute aggression in teens, it must be seen as very preliminary. Like the authors, we too would like to see studies comparing side effect profiles and effective dosages among a range of SGAs.