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Table 3 Suggested adverse event monitoring for selected medications used to treat labeled and unlabeled psychiatric indications in children and adolescents

From: Off-label psychopharmacologic prescribing for children: History supports close clinical monitoring

Drug Class Drug Adverse Events Comment; Monitoring tool
Alpha-Agonists Clonidine Guanfacine Bradycardia; Hypotention; Heart block Rule out congenital heart disease; Blood pressure and heart rate
Stimulants Amphetamines Serious cardiovascular risk [59] Blood pressure and heart rate; ECG where there is a question of congenital heart disease
Anticonvulsant-Mood Stabilizer Divalproex; Valproic acid Polycystic ovaries in girls; malformation rate of 11.1% compared with 3.1% in non-drug exposed fetuses [62]; hepatotoxicity [63]; pancreatitis [64, 65] Discuss risks and provide written information before initiating therapy; girls of child-bearing age should be counseled regarding birth control. Close laboratory monitoring of liver enzymes & coagulation tests in the first 6 months; clinical monitoring for vomiting and apathy; blood levels
  Lamotrigine Rash requiring hospitalization, possible Stevens Johnson Syndrome or hypersensitivity syndrome; serum concentrations doubled when divalproex was added in adjunctive treatment of epilepsy. Indication in those younger than 16 is restricted to Lennox Gastaut Syndrome. Black box warning for potentially life threatening rashes
Antidepressants SSRIs Activation syndrome, suicidality A written diary by the parent of target symptoms and selected adverse events is useful. Regular contact to review information when drug or dose is initiated or changed. Monitor side effects and response regularly
  TCAs Dose-dependent cardiac conduction delays; asystole Baseline and follow-up ECG at therapeutic dose, blood levels.
  Bupropion Dose-dependent risk of seizure Consider alternatives in youth with a history of seizure disorders or bulimia
Atypical Antipsychotics Olanzapine Risperidone Quetiapine Clozapine Ziprasidone Relatively greater weight gain in youths than in adults Extrapyramidal Side Effects (EPS) Hyperprolactinaemia Possible Hyperthyroidism (Quetiapine) Baseline and repeat weight, height and waist circumference, serum fasting lipid and hepatic enzyme levels, thyroid panel (for quetiapine). Fasting glucose level monitoring for the risk of diabetes; diet and exercise management. Monitor quarterly or as indicated for movement disorders with the Abnormal Involuntary Movement Scale (AIMS). Prolactin blood level monitoring in the presence of abnormal sexual signs and symptoms.
Lithium Lithium Thyroid abnormalities; nephrotoxicity; renal concentration diminution; lithium toxicity Lithium levels, baseline thyroid panel, serum creatinine and urinalysis. Repeat periodically, and when dose or regimen changes or symptoms suggest toxicity.