Abstract
U
Case Report
A 15-year-old male adolescent patient was referred to our outpatient clinic with the complaints of tics, obsessive compulsive symptoms, and social incompetence. He was in the ninth grade. Both of his parents were high school graduates. He had a 10-year-old brother. He had been diagnosed with Asperger syndrome at the age of 11 at a university child and adolescent psychiatry clinic. He had been referred to the university clinic with the complaints of social incompetence, socially introverted behavior, monotonous and nonprosodic speech style, anxiety, perfectionism, restricted patterns of interest, and obsessive compulsive symptoms. At the psychiatric examination his nonprosodic and monotonous speech pattern was very prominent, and also he had poor and short eye contact. His memorizing was very good but he had difficullties with mathematics. He had socially phobic attitudes and obsessive compulsive symptoms (cleaning, fear of contamination and touching, continously asking the same questions, being doubtful about hurting people, perfectionism, uncertainty). Also he had had coughing (vocal tic) and multiple motor tics for 1 year. He was diagnosed with Asperger syndrome, obsessive compulsive disorder (OCD), and Tourette syndrome. His parents were informed about his psychiatric condition and citalopram 10 mg/day and aripiprazole 2.5 mg/day were initiated. Low doses were instructed to be used, bcause of his possible vulnerability to psychotropic drug side effects, as he had autism spectrum disorder. The citalopram dose was increased to 20 mg/day on the 10th day of the medical treatment. Three weeks later his OCD findings were 50–60% better, according to him and his parents. The citalopram dose was increased to 30 mg/day on the 3rd week. Three weeks later, his OCD findings and social incompetency were much better, but his tics were only slightly better; therefore, his aripiprazole dose was increased to 5 mg/day. With that dose titration, micturition difficuly and urinary retention developed. He had been admitted to the emergency room for these findings, and his urinary examination and laboratory and radiological findings had not identified any abnormality. The patient's mother thought that the increased dosage of aripiprazole might be responsible for this urinary side effect. When she had administered the dosage of 2.5 mg/day of aripiprazole, there had been no symptoms of micturition difficulty. After the dose was decreased to 2.5 mg/day, there were no urological findings. At follow-up, the patient's tic symptoms gradually decreased. As his OCD symptoms had resolved, in the 6th month of follow-up, his citalopram dosage was decreased to 20 mg/day. We are still following the patient, who is taking citalopram 20 mg/day and aripiprazole 2.5 mg/day, without any urological or other side effects.
Discussion
According to Naranjo classification, point of this side effect was calculated as +9, which refers to “definite adverse drug reaction” (Naranjo et al. 1981). Urinary incontinance, especially caused by typical antipsychotics, is more common (3–6%) than urinary retention. Female gender, older age, prior urinary or bladder problems, treatment with typical antipsychotics, and development of EPS appear to be positive risk factors for developing urinary problems with antipsychotics (Saddichha and Kumar 2009). Our patient had none of these risk factors. Interestingly in two different case reports, Saddichha reported two young adult patients with bipolar disorder who developed urinary incontinance with both typical antipsychotics, but not with aripiprazole (Saddichha 2007; Saddichha and Kumar 2009). However, researchers warned about closely monitoring of possible urinary retention with aripiprazole (Saddichha and Kumar 2009; Lee and Kim 2010; Chiang and Liu 2011). In a case report, clozapine-induced enuresis had been reported to be resolved with aripiprazole in two patients (Lee and Kim 2010), and the authors associated this improvement with aripiprazole's partial agonist effect on 5-HT1A serotonergic receptors and minimal effect on α1 adrenergic receptors (Lee and Kim 2010). Although aripiprazole has minimal effects on α1- and α2-adrenergic receptors and has only a partial antagonist action on D2 dopaminergic receptors, urinary obstruction with aripiprazole alone (Chiang and Liu 2011) or with aripiprazole and citalopram in combination has been reported (Padala et al. 2006). In our case, although urinary retention might have been related to citalopram, this side effect may more possibly have been related to aripiprazole, as the urinary retention had occured and then resolved after variation in the aripiprazole dose. However, we cannot arrive at a final conclusion, because of the complicated drug interactions and because of the earlier reports of urinary retention caused by both SSRIs (Uher et al. 2009; Garakani 2010) and aripiprazole (Chiang and Liu 2010). To our knowledge, this is the first report of urinary retention in a pediatric patient due to citalopram and aripiprazole combination in the medical literature. As urinary retention had been reported previously in an elderly patient, possibly in relation to this drug combination (Padala et al. 2006), clinicians should be careful about urinary side effects when they are using citalopram and aripiprazole in combination in both young and older patients.
Footnotes
Disclosures
No competing financial interests exist.