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Aripiprazole-Induced Diurnal and Nocturnal Enuresis in Down's Syndrome

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Aripiprazole-Induced Diurnal and Nocturnal Enuresis in Down's Syndrome ARIPIPRAZOLE-INDUCED DIURNAL AND NOCTURNAL ENURESIS IN DOWN’S SYNDROME STEFANO MARINI (1) 1 Il Cireneo Foundation for Autism Spectrum Disorder, Vasto, Italy. INTRODUCTION Aripiprazole is an atypical antipsychotic with unique pharmacological profile: partial agonist for dopamine D2 and serotonin 5-HT1A and antagonist for 5-HT2A receptors. Moreover, it also exhibits affinity for dopamine D4, serotonin 5-HT2C, and 5-HT7, alpha 1 adrenergic and histamine H1 receptors [1]. Compared with other atypical antipsychotics, aripiprazole is known to have fewer adverse effects, particularly QTc prolongation, weight gain, and dysregulation of glucose and lipid metabolism, sedation, and prolactin elevation. However, common side effects are represented by headache, tremor, akathisia, nausea, vomiting, constipation, somnolence, dyspepsia, and insomnia. In the clinical practice, aripiprazole is prescribed for psychosis, bipolar disorder, adjunctive treatment of major depressive disorder, Tourette’s syndrome, irritability, and behavioral problems associated with autism spectrum disorder. Past literature highlighted clozapine, risperidone, olanzapine, and quetiapine-induced enuresis. Aripiprazole-induced enuresis has been reported as a very rare adverse effect, but contrasting data has been found in different types of patients. In children, two studies reported an aripiprazole-induced enuresis [2,3], and two studies in adults used aripiprazole to treat enuresis caused by other treatments [4,5]. CASE PRESENTATION 20-years old female drug-naive outpatient affected by Down’s syndrome and mental retardation presented auditory hallucinations, irritability, anger bursts, self-harm and aggression towards others and an increase of stereotyped behaviors. In author’s knowledge, no psychopharmacology guidelines have been published yet for the treatment of psychiatric symptoms in patients affected by Down’s Syndrome. The author decided to start a pharmacological treatment based on aripiprazole monotherapy 5 mg/day. The day after initiating the medication, patient’s family reported a mild improvement in aggressive symptoms. Within two days of initiating aripiprazole, the patient developed new-onset nocturnal and diurnal enuresis with a frequency of 1 to 2 times during the night and during the day. There were no symptoms and signs of urinary tract infection, diabetes or other organic symptomatology related to enuresis. Since enuresis was highly distressing to patient and caregivers, the psychiatrist decided to stop aripiprazole treatment and the enuresis resolved rapidly after discontinuation of the medication. DISCUSSION Micturition is a complex phenomenon involving different anatomical regions, neurological circuits and reflexes. The neural circuitry that controls micturition involves pathways at many levels of the brain (brainstem, prefrontal cortex, anterior cingulate cortex, insula, etc.), the spinal cord and the peripheral nervous system. Moreover, urinary void is mediated by multiple neurotransmitters (glutamic acid, nitric oxide, gamma aminobutyric acid, etc,) at different levels. Dopamine, serotonin, noradrenaline, acetylcholine and non-opioid peptides exert inhibitory or excitatory effects depending on the type of the receptors and the location in the central nervous system. In our case, aripiprazole’s pharmacological profile might have caused alterations in central and in peripheral mechanisms of micturition. In fact, the action on 5HT2A in the detrusor muscle and the alpha-1 antagonism in the internal urethral sphincter might explain the bladder etiology for enuresis. Moreover, the serotonin-induced cholinergic activity in the detrusor muscle might be another mechanism involved. Regarding the central pharmacological activity of aripiprazole, the partial agonist for dopamine D2 receptors might have caused urinary incontinence by decreasing dopaminergic transmission in the basal ganglia and in the prefrontal cortex. The antagonist for 5-HT2A receptors might have gave rise to alterations in pudendal reflexes. Furthermore, the deepness of sleep caused by the sedative effect of H1 antagonism might explain the nocturnal enuresis. CONCLUSIONS Since previous studies reported that people affected by Intellectual Disability and/or Down’s Syndrome have high risk for incontinence the author wants to highlight the importance of a routine assessment of incontinence before, during and after whatever treatment and life-long with regular medical check-ups. REFERENCES [1]Davies, M.A., Sheffler, D.J., Roth, B.L. (2004). Aripiprazole: a novel atypical antipsychotic drug with a uniquely robust pharmacology. CNS Drug Reviews, 10(4), 317-336. [2] Gunes, S. (2017). Aripiprazole-Related Diurnal Enuresis in Children: 2 Cases (Aripiprazole-Related Enuresis). Clinical Neuropharmacology, 40(4), 175-176. [3] Karakurt, M.N., Süren, S. (2015). Desmopressin Use in the Treatment of Aripiprazole-Induced Nocturnal Enuresis in a Child Diagnosed with Autıstıc Disorder. Journal of Child and Adolescent Psychopharmacology, 25(6), 518-519. [4] Lee, M.J., Kim, C.E. (2010). Use of aripiprazole in clozapine induced enuresis: report of two cases. Journal of Korean Medical Science, 25(2), 333-335 [5] Palaniappan, P. (2015). Aripiprazole as a treatment option for clozapine-induced enuresis. Indian Journal of Pharmacology, 47(5), 574-575. Stefano Marini, MD, [email protected] .
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