Prolonged Sedation Following a Pediatric Ingestion of Aripiprazole

Background: Limited data exists regarding the acute adverse effects of aripiprazole in the pediatric population. We describe a case of prolonged sedation following an ingestion of aripiprazole. Case Report: A 2-year-old boy was found with his grandmother's aripiprazole 30 mg tablet in his mouth the night prior to arrival in the emergency department (ED). The day after ingestion, the child spent the day at daycare with abnormally increased drowsiness and lack of PO intake. He was evaluated post ingestion day 1, with a heart rate of 147 bpm, a blood pressure of 134/91 mmHg, a temperature of 98.4 degree F, a respiratory rate of 26, and a bedside glucose was 123 mg/dL. His physical examination was unremarkable. EKG showed a sinus tachycardia at 130 bpm and a QTC interval of 460. Serum electrolytes, liver function tests, urine drug screen, and complete blood count were all within normal limits. A serum ammonia level was found to be elevated at 75 micrograms/dL. CT scan of the head and EEG were normal. The child remained drowsy for 72 hours post-ingestion before finally returning to his baseline mental status. A repeat ammonia level was within normal limits. An aripiprazole level at 24 hours post-ingestion was 150 ng/mL, which is in the therapeutic range. Case Discussion: Aripiprazole has a half-life of 75 hours in CYP2D6 rapid metabolizers which may be prolonged to 146 hours in poor metabolizers. The long half-life of aripiprazole may be problematic in pediatric exposures due to prolonged sedation. Hyperammonemia has not been reported with aripiprazole in prior ingestions, but may play a role in its effects. Previous reports have not described sedation more than 30 hours post-ingestion. Prolonged sedation in the pediatric population may result in excessive invasive and non-invasive testing as well as risks for aspiration and possibly intubation. Conclusion: Symptomatic pediatric ingestions of aripiprazole may produce prolonged sedation.