Letter to the Editor: Acute Hypertriglyceridemia in an Infant Treated with Quetiapine for Pediatric Delirium

Introduction

Delirium is defined by fluctuating disturbances in attention, awareness, and cognition, marking a change from baseline mental status. A clinical pathway for assessment and treatment of pediatric delirium based on available literature and expert consensus has been published (Silver et al. 2019). Nonpharmacologic interventions should be prioritized; pharmacologic interventions may be indicated. Despite lacking Food and Drug Administration approval in children or adults, second-generation antipsychotics (SGAs) such as quetiapine are often utilized to manage delirium (Joyce et al. 2015). One potential side effect of quetiapine is dyslipidemia (Yan et al. 2013). We present a 2-month-old infant who developed hypertriglyceridemia after initiation of quetiapine for management of delirium.

Case

Psychiatry was consulted for possible delirium in a 2-month-old male with pulmonary atresia, ventricular septal defect, and hypoplastic pulmonary arteries whose clinical course is shown in Figure 1. Prior and subsequent to consultation, the child received continuous nasojejunal feeds.

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FIG. 1.

Brief hospital course. c-section, cesarean delivery; desats, desaturations; dc'ed, discontinued; G-tube, gastrostomy tube; mIVF, maintenance intravenous fluids; MV, mechanical ventilation; NJ, nasojejunal; NICU, neonatal intensive care unit; PCICU, pediatric cardiac intensive care unit; QTP, quetiapine; TG, triglycerides.

On day 63, the child had an unplanned extubation with emergent reintubaton. Mental status fluctuations, impaired attention, and dysregulation of affect and sleep–wake cycle were noted on assessments. Nonpharmacologic interventions for delirium were initiated. Given ongoing mental status dysregulation and receipt of multiple pro re nata medications, low-dose quetiapine was recommended. Mental status improved with successful planned extubation and weaning of several sedating medications.

On day 72, his blood was viscous with triglycerides elevated to 573 mg/dL. No baseline was available for comparison. Lacking other explanations for acute hypertriglyceridemia, quetiapine was discontinued. Triglycerides downtrended to 214 mg/dL on day 77.

Discussion

The American Academy of Child and Adolescent Psychiatry practice parameters for use of SGAs suggest that monitoring body mass index, blood pressure, fasting blood glucose, and fasting lipid profiles follows the recommendations of the American Diabetes Association and American Psychiatric Association (Findling et al. 2011). These guidelines do not address metabolic monitoring with short-term SGA use. Following a baseline fasting lipid panel, repeat testing is not suggested until after 3 months.

Likewise, the pediatric delirium clinical pathway does not address monitoring for metabolic disturbances when utilizing SGAs (Silver et al. 2019).

Yan et al. (2013) suggest that SGAs may directly affect triglyceride metabolism through stimulation of hepatic triglyceride production and secretion or through inhibition of lipoprotein lipase-mediated triglyceride hydrolysis; these mechanisms are hypothesized to be independent of obesity or insulin resistance typically associated with long-term SGA use.

To our knowledge, no other cases of acute hypertriglyceridemia associated with quetiapine use in an infant have been reported. Joyce et al. (2015) previously suggested that short-term use of quetiapine [median dose 1.3 mg/kg/day] in children experiencing delirium was safe and without serious adverse events; hypertriglyceridemia was not specifically addressed.

This case highlights the potential risk of hypertriglyceridemia within the first week in infants treated with quetiapine for delirium and importance of obtaining baseline and short-term follow-up metabolic parameters. We propose follow-up studies be obtained within 48–72 hours after initiation, although we acknowledge the need for further study as to time course and age of the patient; it remains unknown whether infants may be particularly vulnerable to this adverse effect.