Antipsychotiques et iatrogénicité : une observation clinique entre effets secondaires et intrication psycho-organique

RésuméL’acte médical de prescription médicamenteuse est guidé par une réflexion clinique recherchant une efficacité thérapeutique tout en minimisant les risques pour le patient. La plupart des psychotropes exposent à des effets iatrogènes de gravité variable, dont le repérage n’est pas toujours aisé, en particulier lorsque s’intrique une affection somatique venant brouiller les repères. L’enfant et l’adolescent semblent plus vulnérables aux antipsychotiques que le sujet adulte, alors qu’une étude prospective multicentrique actuellement en cours en France, l’étude Etape, vise à préciser l’incidence de leurs effets secondaires en population pédiatrique. Une observation clinique est détaillée, en décrivant la démarche diagnostique qui permettra l’identification d’une atteinte hépatique primitive inconnue jusqu’à lors chez un adolescent âgé de 17 ans présentant un trouble délirant sévère. Les importantes fluctuations du bilan hépatique jusqu’à un épisode d’hépatite aiguë orienteront initialement vers une origine toxique médicamenteuse imputable aux antipsychotiques ; une cause organique associée sera finalement retrouvée, après de nombreux aléas compliquant la prise en charge d’un état psychiatrique grave lequel imposait un traitement adéquat.

BackgroundComorbidity is defined as the existence or the occurrence of at least two distinct pathologies occurring in the same subject, simultaneously or delayed. Comorbidities between mental disorders and somatic disorders are often not readily recognized and are under-diagnosed. Their impact is yet significant, both in terms of prognosis and impact on the quality of patients’ life. The medical procedure of drug prescription is guided by a clinical reflexion, which seeks therapeutic efficiency while minimizing the risks for the patient. The side effects identification is not always easy, especially when combined with a somatic disease that may confuse the benchmarks. Children and adolescents are traditionally more vulnerable than adults; a controlled study named ETAPE is currently carried out in France in order to precise the incidence of side effects of antipsychotics in a pediatric population.MethodsA brief summary of the liver tolerance of antipsychotics is specified from the most salient features of the literature. A clinical observation of a 17 years old adolescent is then described in order to pinpoint at the problematic of identification and distinction of what belongs to a psycho-organic intricacy or to iatrogenic effects of antipsychotics.DiscussionThe existence of a comorbidity is revealed in our case report by a precipitating factor, the administration of antipsychotics. The lesion of biliary tracts was probably old, but up to now silent, due to the absence of external factor likely to trigger its pathophysiological expression. The iatrogenic effects of antipsychotic treatment have been increased by the lesion of biliary tracts, promoting local accumulation of liver metabolites and their toxicity. The treatment of the underlying somatic disease has resolved the issue of antipsychotics metabolism, improving their liver tolerance and enabling the pursuit of their prescription. In front of this clinical picture of hepatotoxicity, various elements have guided clinical thinking to recognize the existence of a somatic cause associated with drug factor: data from literature retain the scarcity of cross-reactions between atypical antipsychotics, yet here observed. The early onset of liver pain, with a deterioration in less than seven days of the liver function tests; the initially isolated elevation of gamma-glutamyl transferases, which are not the most common marker of liver pain selected by the literature, then its slower decrease could suggest a previous lesion of the biliary tracts. The fluctuation of the liver function tests was indeed correlated with medication changes, but variations in liver enzymes were observed several times during hospitalization without any change in the treatment.ConclusionThe differential diagnosis between the iatrogenic effects of antipsychotics and a potential psycho-organic intricacy is essential, particularly in the management of severe psychiatric disorders requiring appropriate treatment, but whose maintaining is conditioned by its good tolerance. Antipsychotics prescription is guided by the assessment of the risk/benefit ratio of the selected molecule, always seeking the lowest effective dose. For all that an imperative of our diagnostic process is to eliminate an underlying organicity when it comes to psychiatric disorder, with an adjustment of the care close to the clinical condition of our patients.