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Can Risperidone Increase The Risk Of Seizure?
Question: Hi there...I am from Australia and would like your opinion. My son XXXXXXX is 30 years old, has classic Autism with Epilepsy as well (Tonic Clonic seizures). He is 6ft 4in & weighs 90kg. He has had 3 seizures in the last 18 months with the last one causing him serious damage to his face & head. He was on Topamax (Topirimate) but has now changed to Sodium Valproate (Epilim)...now on 2000mg a day. He did get a slight rash across the nose & cheeks and still has it but hoping it may settle. Has been on the full dose rate now for a couple of weeks. He was also taking Risperdal to keep him settled and calmer but I've been told it may be causing the Seizure breakthroughs. He was on 4mg a day. So he was given Paxam (Clonazepam) to replace Risperdal but he is still very unsettled...loud & obnoxious really, very repetitive talk(non-stop)...just words - not relevant talk. He only has 2-3 word phrases and mostly repetitive at the best of times. A higher dose of Paxam sedated him too much which I don't really want. He was quite manageable & happy with the Risperdal so I am tempted to put him back onto it...maybe only 2mg a day. He was quite aggressive as a young fella and he has been so good 90% of the time with the Risperdal. I have also read about Straterra and Guanfacine for ADHD symptoms. Would either of these help or can you suggest another drug to try to calm him down. Do you think there is a risk of bringing on seizures by putting him back on Risperdal of 2mg a day as I have been told the Epilim is a better medication for Tonic Clonic seizures rather than Topamax so thought maybe the Risperdal might not interfere with it or the actual Epilepsy as much. I realize there is no guarantee of no seizures but he hadn't had any for about 10 years prior to these last three turns. He only developed epilepsy at age 18. He also has troubling getting words out at times...like a stutter. I thought this may have been from the Topamax or the Risperdal but still has trouble even though we have stopped both of these now. I thought he may settle with just the Epilim and no Paxam or Risperdal but I still feel he needs something to calm the Autism side of things. Thanking you...XXXX
Brief Answer:
Read below.
Detailed Answer:
I read your question carefully and I understand your dilemma.
The two drugs you have tried represent the two main groups used to control agitation in patients like your son, benzodiazepines (clonazepam) and antipsychotics (risperdal).
In terms of effect on seizures it is true that Clonazepam is better as it is an anticonvulsant, but apart from not being effective enough in your case, it can also develop tolerance over the time (same dose is not as effective).
Antipsychotics have rather good efficacy, but unfortunately all of them do confer some increased seizure risk, so there is not a better alternative in this group. Actually among them Risperdal is the best choice as it's the one with less seizure risk among them.
ADHD drugs are not typically studied or used for your purpose and considering they are nervous system stimulants I do not really see any benefit from them.
So what to do once this information is considered...as you said yourself there is no guarantee of no seizures. Since he was so much better controlled with Risperdal and he was seizure free for 10 years before (I am assuming he was taking Risperdal during that time), I would give it a try at a lower dose. If his situation fluctuates another option might be giving it not on a regular basis but only on days when he's more agitated than usual.
Again it's not the perfect solution, it's more about choosing the minor evil to ensure a better quality of life for him as well as family members.
I remain at your disposal for other questions.
Read below.
Detailed Answer:
I read your question carefully and I understand your dilemma.
The two drugs you have tried represent the two main groups used to control agitation in patients like your son, benzodiazepines (clonazepam) and antipsychotics (risperdal).
In terms of effect on seizures it is true that Clonazepam is better as it is an anticonvulsant, but apart from not being effective enough in your case, it can also develop tolerance over the time (same dose is not as effective).
Antipsychotics have rather good efficacy, but unfortunately all of them do confer some increased seizure risk, so there is not a better alternative in this group. Actually among them Risperdal is the best choice as it's the one with less seizure risk among them.
ADHD drugs are not typically studied or used for your purpose and considering they are nervous system stimulants I do not really see any benefit from them.
So what to do once this information is considered...as you said yourself there is no guarantee of no seizures. Since he was so much better controlled with Risperdal and he was seizure free for 10 years before (I am assuming he was taking Risperdal during that time), I would give it a try at a lower dose. If his situation fluctuates another option might be giving it not on a regular basis but only on days when he's more agitated than usual.
Again it's not the perfect solution, it's more about choosing the minor evil to ensure a better quality of life for him as well as family members.
I remain at your disposal for other questions.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Thank you for your prompt reply. What would you consider a low dose then of Risperdal? Since writing last night, I have given him 1/2 tab (1mg) at 2am this morning as he is just not sleeping or settling since going on Epilim (Valproate). It doesn't seem to make him sleepy at all...the opposite really. He is just repeating words over & over and laughing. Not really cranky which is something I guess. His mind just seems to be racing and working overtime. I gave him another 1mg today. He is due to have his first blood test this week since the changeover. He still has the rash across his cheeks below the eyes. Another doctor suggested Keppra but I have more confidence in Epilim as the first choice for tonic clonic seizures so was wondering what you feel about that drug also just in case he doesn't settle down with the Epilim. Would you be inclined to stick with the Risperdal rather than the Clonazepam? Thank you again.
Brief Answer:
Read below
Detailed Answer:
Thank you for the update.
For a person of his weight I would consider 2 mg a day to be a low dose. Dosages can go up to 8mg, but with the fearing for seizures that dosage should be avoided. Since you say it was effective before one should expect it to have some effect.
I would like to return to the previous consideration about ADHD used stimulants. Because risperdal is usually used for irritability and agitation, I was referring to that indication when saying they shouldn't be effective. Since from what you say though, seems that it's more a question of hyperactivity, repetitive behavior, in that case there can be some benefit with those drugs and their use can be considered. They are not as effective as in ADHD hyperativity, but can produce an improvement in symptoms and are not known to lower seizure threshold.
Another option are also SSRI antidepressants which also improve repetitive behaviors and mood but they do carry the increased seizure risk.
As for the antiepileptic, Keppra is a very good drug which can also be used for generalized seizures. However so is Epilim, it's a first choice drug. Since he's already started on it I believe it's not in our interest to jump from one drug to another without a proper motivation. A motive would be if time shows it not to prevent his seizures or develops serious side effects, since we are still at the early stages of therapy it's too soon to say that, for the moment Epilim is a fine choice, only if those issues arise Keppra can be discussed.
I hope to have been of help.
Read below
Detailed Answer:
Thank you for the update.
For a person of his weight I would consider 2 mg a day to be a low dose. Dosages can go up to 8mg, but with the fearing for seizures that dosage should be avoided. Since you say it was effective before one should expect it to have some effect.
I would like to return to the previous consideration about ADHD used stimulants. Because risperdal is usually used for irritability and agitation, I was referring to that indication when saying they shouldn't be effective. Since from what you say though, seems that it's more a question of hyperactivity, repetitive behavior, in that case there can be some benefit with those drugs and their use can be considered. They are not as effective as in ADHD hyperativity, but can produce an improvement in symptoms and are not known to lower seizure threshold.
Another option are also SSRI antidepressants which also improve repetitive behaviors and mood but they do carry the increased seizure risk.
As for the antiepileptic, Keppra is a very good drug which can also be used for generalized seizures. However so is Epilim, it's a first choice drug. Since he's already started on it I believe it's not in our interest to jump from one drug to another without a proper motivation. A motive would be if time shows it not to prevent his seizures or develops serious side effects, since we are still at the early stages of therapy it's too soon to say that, for the moment Epilim is a fine choice, only if those issues arise Keppra can be discussed.
I hope to have been of help.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Thank you again. 2mg Risperdal is also what my local GP suggested if not going with the Paxam which I've decided not to now as he was yelling out loudly and agitated after giving it to him even in small doses. So that is good to hear that from you also. It does make me nervous though knowing it can cause seizure breakthroughs. Should I split this dose morning & night or give him the 2mg in one dose...morning or night? I am going to try to continue the Epilim and hope that he settles. We will see what the blood levels show. What do you think would be the correct Epilim dose for his size? He is now taking 1000mg in the morning and again at night...so 2000mg per day. Do you think the rash on his face would be connected to taking Epilim as that is when it started? If so, what would it mean or is it something to do with digestive inflammation and is it likely to settle down? I was hoping the Epilim might help calm him down but seems to have had the opposite effect so far. He was quite happy before with the Topamax & Risperdal but he was taking 4mg of Risperdal then so hopefully we can manage on 2mg now. I am also concerned about a stutter he gets now...having trouble getting words out sometimes but he started this while on the Topamax & Risperdal so not sure whether it was the drugs that has caused it or could it be from the actual seizures? He was stuttering quite badly the day before his last turn. We live in a rural area some distance from a Specialist so I appreciate your help. If you can recommend any other treatments for autism behaviours without interference to the epilepsy, that would be appreciated. It is quite common for them to have digestive/gut issues as well. If he doesn't settle I will have to make an appointment for the city. Thanks again.
XXXX. (Hopefully I can leave you alone soon.)
Forgot this question:
Do you have a preferred SSRI that you have found to be effective for these kids...he does have a lot of repetitive behaviours and strong compulsions. I hope not to have to use them unless you think it may be a better choice than the Risperdal (with the epilepsy in mind) but would be interested in your opinion in case needed. Thank you.
XXXX. (Hopefully I can leave you alone soon.)
Forgot this question:
Do you have a preferred SSRI that you have found to be effective for these kids...he does have a lot of repetitive behaviours and strong compulsions. I hope not to have to use them unless you think it may be a better choice than the Risperdal (with the epilepsy in mind) but would be interested in your opinion in case needed. Thank you.
Brief Answer:
Read below
Detailed Answer:
Regarding the first question, usually I divide the Risperidal dose in half, but if his periods are more pronounced at one time of the day it might be considered using more before that period. Also regarding its effect on seizures, perhaps your son have seizures at different times, but there are some epilepsy patients who get seizures only at certain times, such as during the day, early hours of sleep, upon awakening, in that case could be considered not to give the risperdal in the hours preceding that time frame.
Dosage of Epilim can vary from patient to patient, ranging from 1000-2500mg, most commonly for a big size guy as your son at 1500-2000 mg are used, but the levels will give also some indication as it can vary according to individual metabolism.
As for the skin changes, they are not common but can be present, as rashes or photosensitivity to light, actually if it had happened today I would've told you to stop the drug and have those skin reactions looked at by the doctor, but since some time seems to have passed and they seem to be self contained you can give it some more time as it might resolve.
Epilim should help in stabilizing mood and settling him, that is true, for the lack of a better explanation perhaps Risperdal interruption was the cause.
Apart from the medication we already discussed there is not much else available. SSRI as I said are commonly used, they have similarities between them, but citalopram and escitalopram are among the most used and the least seizure related.
Compared to antipsychotics the risk is similar to risperdal, I believe it's about 0.2% for them and 0.3% for Risperdal so practically the same to be honest (of course those figures are in people with no known seizure history, would be higher in seizure prone population). Of the medication options discussed only clonazepam is safe, so should be the ADHD stimulants from the little studies there are in epilepsy population.
Read below
Detailed Answer:
Regarding the first question, usually I divide the Risperidal dose in half, but if his periods are more pronounced at one time of the day it might be considered using more before that period. Also regarding its effect on seizures, perhaps your son have seizures at different times, but there are some epilepsy patients who get seizures only at certain times, such as during the day, early hours of sleep, upon awakening, in that case could be considered not to give the risperdal in the hours preceding that time frame.
Dosage of Epilim can vary from patient to patient, ranging from 1000-2500mg, most commonly for a big size guy as your son at 1500-2000 mg are used, but the levels will give also some indication as it can vary according to individual metabolism.
As for the skin changes, they are not common but can be present, as rashes or photosensitivity to light, actually if it had happened today I would've told you to stop the drug and have those skin reactions looked at by the doctor, but since some time seems to have passed and they seem to be self contained you can give it some more time as it might resolve.
Epilim should help in stabilizing mood and settling him, that is true, for the lack of a better explanation perhaps Risperdal interruption was the cause.
Apart from the medication we already discussed there is not much else available. SSRI as I said are commonly used, they have similarities between them, but citalopram and escitalopram are among the most used and the least seizure related.
Compared to antipsychotics the risk is similar to risperdal, I believe it's about 0.2% for them and 0.3% for Risperdal so practically the same to be honest (of course those figures are in people with no known seizure history, would be higher in seizure prone population). Of the medication options discussed only clonazepam is safe, so should be the ADHD stimulants from the little studies there are in epilepsy population.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Thank you Doctor...you have put my mind at ease a little more. You speak a lot of sense. Andrew's seizures have all happened in the mornings just after waking so today I just gave him the 1mg of Risperdal at breakfast time after he had been up for a while. He has been quite good today although still a bit restless. I will see if we can manage without any Risperdal tonight and just give him that small dose again after breakfast. The rash is still there but not spreading. Would you know what it might mean and if it doesn't disappear, should I be concerned? Also would you know what the % rate from Risperdal would be for seizure breakthroughs in the seizure prone population? Thanks again.
Brief Answer:
Read below.
Detailed Answer:
The rash would of course be considered in light of an allergic reaction. Considering the distribution in the nose and cheeks and if you have noticed any relation to exposure to the sun can be a case of photosensitivity, a special type of photoallergy related to the drug in the setting of exposure to light, in that case sun protection with creams might help.
Generally speaking an allergic reaction to a drug would call for the withdrawal of the drug, I just wouldn't want to make that call in the absence of the possibility of examining the patient and given that it is not an acute reaction which wouldn't wait till you meet your doctor.
As for seizures in the seizure prone population I couldn't find any such data in percentage, I assume it would be hard to assess in a patient with a history of seizures whether that seizure was really related to risperdal or just a coincidental seizure which would have happened anyway in that seizure prone individual, not being an exact call studies would be difficult.
Read below.
Detailed Answer:
The rash would of course be considered in light of an allergic reaction. Considering the distribution in the nose and cheeks and if you have noticed any relation to exposure to the sun can be a case of photosensitivity, a special type of photoallergy related to the drug in the setting of exposure to light, in that case sun protection with creams might help.
Generally speaking an allergic reaction to a drug would call for the withdrawal of the drug, I just wouldn't want to make that call in the absence of the possibility of examining the patient and given that it is not an acute reaction which wouldn't wait till you meet your doctor.
As for seizures in the seizure prone population I couldn't find any such data in percentage, I assume it would be hard to assess in a patient with a history of seizures whether that seizure was really related to risperdal or just a coincidental seizure which would have happened anyway in that seizure prone individual, not being an exact call studies would be difficult.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
OK...thank you very much for all your advice. Much appreciated.
XXXX
XXXX
Brief Answer:
You're welcome. Thank you.
Detailed Answer:
I sincerely hope things will get better soon for you and your son.
You're welcome. Thank you.
Detailed Answer:
I sincerely hope things will get better soon for you and your son.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
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