Kentucky's Medicaid program has spent more than $40 million since 2001 filling prescriptions for certain powerful drugs that help youngsters with emotional problems, but also could pose risks for their physical health.
Now, the program's medical director, Dr. Thomas Badgett, wants to rein in prescriptions for so-called "atypical anti-psychotic" drugs in children. Badgett plans to launch an effort early next year alerting Kentucky Medicaid providers to prescribe the drugs for youngsters only when their use is appropriate and to carefully monitor patients for problems.
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Similar efforts in other states have reduced prescriptions of atypical anti-psychotics and saved millions of dollars, officials say.
Atypical anti-psychotics are a relatively new class of drugs often prescribed for conditions in both adults and children such as schizophrenia, bipolar disorder and irritability associated with autism. But mounting evidence suggests that they also can cause dramatic weight gains in some children and put youngsters at increased risk for Type II diabetes.
Badgett said an in-house assessment three years ago showed Kentucky Medicaid was "spending an incredible amount of money" on atypical anti-psychotics, and that many young Medicaid patients were taking four or more of the potent drugs at the same time, often obtaining them from multiple prescribers. According to Badgett, 42,000 Kentucky children under age 18, including children in foster care, were receiving atypical anti-psychotics through Medicaid as recently as 2005. He said numbers have been dropping since then.
According to figures provided by the state, Medicaid has spent more $40 million since 2001 filling prescriptions of just three atypical anti-psychotics — Geodon, Seroquel and Zyprexa — for Kentucky youngsters covered by the medical welfare program. Prescriptions for those drugs were filled more than 25,000 times during the period, the figures show.
Badgett, who is a pediatrician, said he began questioning such drugs when he was in private practice before joining Medicaid in 2004.
"I would have young patients go off to see a behavioral health specialist, and some would come back on these drugs," he said. "Frequently, they would experience just an incredible weight gain.
"That can be very emotionally upsetting to a young person, even though these drugs are supposed to deal with emotional problems. I got quite concerned about it."
Some recent studies suggest that atypical anti-psychotics could be no more effective that some older anti-pschyotic medications in treating emotional problems. Physicians and other experts also acknowledge that the atypicals do pose a risk for rapid weight gain in children, with reports of some young patients quickly putting on 30 pounds or more.
But Robert Kuhn, a pharmacy professor at the University of Kentucky, said atypical anti-psychotics do offer a significant advantage: They are less likely to cause young patients to develop movement disorders, such as jerks or tics, than the older drugs are.
"Clearly, there are some children who are going to do better on these drugs than on more traditional medications," he said.
Kuhn added that regular monitoring of young patients' weight, glucose levels and other markers should enable doctors to spot early signs of weight gains or other risks and head them off by switching to other drugs or putting patients on exercise programs.
In extreme cases, some weight gain might be a worthwhile trade-off, some practitioners suggest.
"When it's a choice between a child having to be in a hospital and away from the family for the rest of its life, or to be on the drug and stay at home, gaining 10 pounds over six months might be much better," said Dr. Paul Glaser, a pediatrician and child psychiatrist at UK. "My hope is that Medicaid doesn't force us to use the older drugs."
Badgett said he has no intention of doing that.
Part of the problem, he said, is that Kentucky has a shortage of child psychiatrists and other behavioral health specialists. As a result, he said, many anti-psychotic drug prescriptions are being written for children by family care doctors, pediatricians and other generalists who may not be familiar with the latest information on potential risks.
He said that could explain how young patients might end up taking multiple drugs at the same time.
"I'm sure physicians try one option, and if that doesn't work they add another option," he said. "Then, if the child's parents move to another provider it's very easy for problems to creep in. It can happen without a physician knowing it."
To prevent inappropriate prescriptions, Badgett plans to use an educational program developed by Comprehensive NeuroScience Inc. of White Plains, N.Y., to monitor prescriptions of anti-psychotic drugs in Kentucky. Medicaid programs in at least 19 states already use the program.
Missouri, the first state to implement it, reported saving $7.7 million in fiscal 2004 by reducing inappropriate prescriptions.
Badgett said that as a first step Medicaid will send letters after the first of the year to prescribers across Kentucky with the latest information about atypical anti-psychotics, their risks in children, and generally accepted guidelines for prescribing the drugs.
The main goals, officials say, will be to identify and educate practitioners who may be prescribing the drugs inappropriately. The goal is to prevent situations in which patients get drugs from multiple prescribers or take multiple medications at the same time.
"These drugs can make a difference between light and day in a child's life," Badgett said. "But we need to make sure they are used appropriately."