Published: 6 December 2019

Publications

The use of serotonin reuptake inhibitors in children and adolescents

Prescriber Update 40(4): 78–80
December 2019

Introduction

Serotonin reuptake inhibitors (SRIs) are not approved in New Zealand for use in children and adolescents for depression or anxiety^1–4. For the purposes of this article, SRIs includes selective serotonin reuptake inhibitors (SSRIs) and serotonin and noradrenaline reuptake inhibitors (SNRIs).

Section 25 of the Medicines Act 1981 permits an authorised prescriber to use any medicine (approved or unapproved) for the treatment of a particular patient in his or her care⁵. However, regardless of whether the authorised prescriber uses approved or unapproved medicines, he or she must provide care of an adequate professional and ethical standard⁵. The decision to use SRIs in children and adolescents should be made in consultation with the patient and their parents/caregivers, ensuring that they are fully informed about the potential benefits and harms of taking the medicine.

The Best Practice Advocacy Centre New Zealand (bpac^NZ) recommends non-pharmacological approaches as the preferred first line treatment for patients aged under 18 years with anxiety disorders or depression⁶. Treatment should acknowledge the ongoing importance of family support, sleep, good nutrition and exercise⁶. Local clinical guidelines should also be considered.

Usage data

Fluoxetine was the most frequently dispensed SRI in children between 2014/15 and 2018/19, as shown in Table 1 (children and adolescents aged under 18 years) and Table 2 (children aged under 12 years).

Table 1: Number of children and adolescents aged under 18 years who have received at least one initial dispensing of SRIs between 2014/15 and 2018/19

Financial Year	Number of children and adolescents aged under 18 years
	Citalopram	Fluoxetine	Paroxetine	Venlafaxine
2014/15	1913	4965	232	281
2015/16	1951	5475	225	327
2016/17	1715	5815	236	387
2017/18	1538	6223	177	403
2018/19	1441	6680	161	356

Source: The data is sourced from the Pharmaceutical Collections as at 21 July 2019. The data is not a validated statistic and therefore considered unofficial. However, it provides a good estimation of how many children and adolescents are receiving SRIs and the trends over time.

Table 2: Number of children aged under 12 years who have received at least one initial dispensing of SRIs between 2014/15 and 2018/19

Financial Year	Number of children aged under 12 years
	Citalopram	Fluoxetine	Paroxetine	Venlafaxine
2014/15	166	536	5	1
2015/16	168	588	3	9
2016/17	157	653	7	8
2017/18	133	725	7	5
2018/19	132	740	6	1

Source: The data is sourced from the Pharmaceutical Collections as at 21 July 2019. The data is not a validated statistic and therefore considered unofficial. However, it provides a good estimation of how many children are receiving SRIs and the trends over time.

New Zealand case reports

From 1 July 2014 to 30 June 2019, the Centre for Adverse Reactions Monitoring (CARM) received 27 case reports in patients aged under 18 years, where at least one of the suspect medicines was an SRI. There were:

• 2 reports for citalopram
• 19 reports for fluoxetine
• 3 reports for sertraline
• 4 reports for venlafaxine.

(One case report was for a patient taking fluoxetine and sertraline, so the sum of the medicine reports does not match the number of case reports.)

The adverse effects reported included (in alphabetical order): abdominal discomfort, abnormal behaviour, abnormal feelings, aggression, confusion, drug interaction, dyspnoea, electric shock sensation, fever, flatulence, gastroesophageal reflux, hallucinations, headache, malaise, muscle contractions, nausea, panic, pruritus, rash, somnolence, tiredness, tremor and vertigo. Muscle contractions could indicate possible serotonin syndrome.

Six reports were associated with changing brand of SRI.

There was one report of suicidal tendency (CARM ID number 113375), where fluoxetine and sertraline were both the suspect medicines.

Adverse events in young patients tend to be more common and more severe, so it is important to closely monitor a child or adolescent who has been prescribed an SRI⁶.

Suicidality

Suicidality (suicidal thoughts and behaviours¹) is associated with a number of medicines, including SRIs^7,8.

Prescribers are reminded to inform patients and their parents/caregivers of an increased risk of suicidality with SRIs⁷. Advise patients to seek medical advice immediately if they experience changes in mood or behaviour that may be suggestive of suicidality⁷. Clinicians should also be alert to signs of akathisia, as this may be associated with suicidality⁸.

References

1. PSM Healthcare Limited t/a API Consumer Brands. 2017. Citalopram New Zealand Data Sheet June 2017. URL: www.medsafe.govt.nz/profs/Datasheet/c/citalopramtab.pdf (accessed 16 July 2019).
2. Teva Pharma (New Zealand) Limited. 2019. Arrow – Fluoxetine New Zealand Data Sheet April 2019. URL: www.medsafe.govt.nz/profs/Datasheet/a/arrowfluoxetinetab.pdf (accessed 16 July 2019).
3. Apotex New Zealand Limited. 2019. Apo-Paroxetine New Zealand Data Sheet March 2019. URL: www.medsafe.govt.nz/profs/Datasheet/a/ApoParoxetinetab.pdf (accessed 16 July 2019).
4. Mylan New Zealand Limited. 2019. Enlafax XR New Zealand Data Sheet May 2019. URL: www.medsafe.govt.nz/profs/Datasheet/e/enlafaxXRcap.pdf (accessed 16 July 2019).
5. Medsafe. 2014. Use of unapproved medicines and unapproved use of medicines. URL: www.medsafe.govt.nz/profs/RIss/unapp.asp (accessed 5 August 2019).
6. bpac NZ. 2016. The role of medicines for the treatment of depression and anxiety in patients aged under 18 years. Best Practice Journal March 2016. URL: https://bpac.org.nz/BPJ/2016/March/depression-anxiety-under18.aspx (accessed 8 July 2019).
7. Medsafe. 2010. Suicidality: a rare adverse effect. Prescriber Update 31(1): 7. URL: www.medsafe.govt.nz/profs/PUArticles/Suicidality%20-%20a%20rare%20adverse%20effect.htm (accessed 22 July 2019).
8. Sharma T, Guski LS, Freund N et al. 2016. Suicidality and aggression during antidepressant treatment: systematic review and meta-analyses based on clinical study reports. BMJ 352: i65. DOI: https://doi.org/10.1136/bmj.i65 (accessed 23 October 2019).