Presentation is loading. Please wait.

Presentation is loading. Please wait.

Dr Gordon Bates Huntercombe Hospital University of Birmingham

Similar presentations

Presentation on theme: "Dr Gordon Bates Huntercombe Hospital University of Birmingham"— Presentation transcript:

1 Dr Gordon Bates Huntercombe Hospital University of Birmingham
Psychotherapeutics in Child Psychiatry THE BPPA - BAPA ANNUAL CONFERENCE 2011 Saturday 18th November Dr Gordon Bates Huntercombe Hospital University of Birmingham

2 Overview Basic Principles Range of medications Antipsychotics
Antidepressants ADHD treatments: Stimulants Atomoxetine Alpha agonists

3 Principles of Child Pharmacokinetics
Children are not small adults Area is less well researched Rates of absorption in children are faster and peak levels are reached faster (esp. liquids)

4 Proportion of Water in Body through Life

5 Volume of distribution results for the full database (22 substrates)
Volume of distribution results for the full database (22 substrates). *p < 0.1. Volume of distribution results for the full database (22 substrates). *p < 0.1. Ginsberg G et al. Toxicol. Sci. 2002;66: © 2002 Society of Toxicology

6 Clearance results for the full database (27 substrates). p < 0. 01;
Clearance results for the full database (27 substrates). *p < 0.01; **p < Clearance results for the full database (27 substrates). *p < 0.01; **p < Ginsberg G et al. Toxicol. Sci. 2002;66: © 2002 Society of Toxicology

7 Principles of Child Pharmacokinetics II
Hepatic metabolism is almost double adult rate in middle childhood and approaches adult rates by 15 years Fat stores in children act to slow elimination of liposoluble drugs (e.g. fluoxetine, pimozide) Cytochrome P450 2d6 and 2c19 unaffected by age but remember racial effects

8 When to use Medication Is it bad enough? Is it pervasive?
Have psychological strategies or environmental modification been tried? Is it part of a wider treatment package? Do parents and adolescent give consent? Is it licensed/unlicenced or off indication? Is it an emergency? Risk/Benefit analysis

9 How to use Medication Monotherapy is better than polypharmacy
Develop a range of familiar drugs Start low and go slow Review frequently Consider use of rating scales Monitor for side effects Monitor for drug/drug interactions Pharmacogenomics: the future?

10 Range of Treatments Anxiolytics Sedatives and Melatonin Antipsychotics
Antidepressants: Fluoxetine Mood stabilisers ADHD treatments Mostly unlicensed for children

11 Prescribing to children: Licensed or unlicensed in UK
Antipsychotic Child (<12) Adolescent (12-18) Chlorpromazine Yes Haloperidol oral Haloperidol IM No Pimozide Trifluoperazine Yes (anxiety) Sulpiride Yes (>14) Zuclopenthixol IM Amisulpiride Yes(>15) Clozapine Yes(>16) Olanzapine oral Olanzapine IM Risperidone oral Risperidone IM

12 Antipsychotics Haloperidol and Chlorpromazine have license
Unlicensed Olanzepine, Risperidone and Aripiprazole most commonly used in UK practice Wide range of usage: Psychosis Bipolar Tourette’s Rapid tranquillisation Mood swings in Borderline Personality Disorder Irritability in ADHD and Autism

13 NICE recommendations Predominantly aimed at adults and remaining within product licence: Atypical antipsychotics (TA 43 June 2002) Core Interventions in Schizophrenia (CG 1 Dec 2002) Bipolar Disorder (CG38 July 2006) Violence & Acute behavioural disturbance (CG25 Feb 2005)

14 How to choose Personal experience Side effect profile
Family history of response Patient or carers preference “local expert”

15 Side Effects of Antipsychotics (Bazire 2007)
Drug AntiCh Cardiac EPSE Low BP Sedation Minor O/D Wt gain Prolactin Proconvulsant Aripiprazole - + ? Olanzapine ++ +++ Quetiapine Risperidone Zotapine Clozapine Amisulpiride ?+ Chlorpromaz Haloperidol

16 Antidepressants Depression in childhood and adolescence has similarities and differences to adulthood Response to medication is different Tricyclics ineffective in Childhood depression SSRI controversy: suicidality and mood lability in early treatment CSM and NICE guidance: Psychological therapies first If medication indicated only Fluoxetine first line

17 Father of Child Psychopharmacology
14 of 30 children showed a ”spectacular change in behavior… remarkably improved school performance” Serendipity Given after pneumo- encephalography Children called them their “arithmetic pills” (Am J Psych 1937)

18 Potential Mechanisms of Action
Dopamine- Reuptake inhibition and direct release Methylphenidate Dexamphetamine Dopamine-reuptake inhibitor Modafanil Noradrenaline-Agonists L-amphetamine Noradrenaline-reuptake inhibitor Atomoxetine Alpha 2 adrenergic - agonists Clonidine Guanfacine

19 Stimulants Licensed Methylphenidate Dexamphetamine Unlicensed
L-amphetamine mixed salts (Adderall) Modafanil

20 Features of Stimulant activity
Greatest effects on Attention and restlessness Less useful for impulsive behaviours Rapid acting Short half life Clear dose effect relationship Well established side effect profile

21 Dose Response of Methylphenidate on Attention in clinic and classroom (Rappoport et al 1987)

22 Efficacy of the stimulants
Educational intent: to illustrate the efficacy of stimulant treatment according to various parameters SPEAKERS’ NOTES So far, stimulants are the gold standard pharmaceutical treatment for ADHD. However, pharmaceutical management should not be expected to solve all the problems associated with ADHD symptoms. Responder rate (%) 75-90 Methylphenidate 75 Amphetamine 70 Normalisation rate (%) 50-60 Symptom improvement (%) Behaviour scales 30-50 Effect size (SD) Behaviour high Attention 0.7 medium IQ/ Performance tests 0.3 low

23 Long Acting Stimulants
Time of effect Comments Methylphenidate Equasym XL 6-8hrs School day cover Medikinet Concerta® XL 8-12hrs Sleep and appetite Daytrana ® hrs Transdermal US only Amphetamine compounds Adderall XR 6-8hrs Import only Vyvanase 12-14hrs Prodrug, ltd abuse (lisdexamfetamine) Awaiting UK approval Medication management plays a central role in the management of most patients with ADHD. Stimulants are recommended as first-line therapy for patients with ADHD. This slide shows the advantages and disadvantages of various stimulants used to treat ADHD.

24 Transdermal Methylphenidate (Daytrana)
Doses: 10mg, 15mg, 20mg 30mg Applied to hip each morning Stays on after swimming or bathing Irritation rare Suggested use for 9 hours but effects last 3 hours after removal Heal and Pierce CNS drugs (2006)

25 Lisdexamfetamine (Vyvanase)
Metabolised in GI tract to Lysine and Dexamphetamine Doses: 30mg, 50mg, 70mg Little euphoric effect reducing abuse potential Clin Ther 2007;29:

26 Side Effects Anorexia, weight loss Give with meals Use supplements
Dietary advice Insomnia Give earlier Use shorter acting prep Consider melatonin/clonidine Rebound Change to long acting prep Assess timing and overlap Dysphoria Consider comorbidity and treat Change to long acting or alternative stimulant

27 Cardiovascular Risk Sudden death rates in General Population:
0.6-6/100,000 children per year 1/1000 adults per year Estimated sudden death rate on Stimulants: 0.25/100,000 people per year based on Rx data 0.5/100,000 people per year (assuming 50% under- reporting) FDA reevaluation 24/3/2006: No additional risk in medically healthy children

28 Atomoxetine Recent analyses suggest:
Children similar to adolescents for outcome Monitor height and weight esp in younger children Some response by week 2 but continue to weeks Reduction in irritability precedes core symptom improvements

29 Atomoxetine Niches Treatment resistance, partial response
Intolerable side effects Importance of all day cover Possible substance misuse or diversion Comorbid anxiety disorder Tic disorder

30 Atomoxetine Side Effects:
Somnolence, insomnia, nausea, headache, reduced appetite, abdominal discomfort, raised BP and pulse, sexual dysfunction Drug Interactions: Care with some SSRIs (fluoxetine and paroxetine) No interaction with stimulants or alcohol

31 Atomoxetine Rare hepatitis reported
1 confirmed case in 3.4 million prescriptions 1 further suspected case in 3.4 million prescriptions Implications: Discuss rare event not routine LFTs Known increase in mood lability in 3% Possible slight increase in suicidal ideation 0.037% Atomoxetine v 0% Placebo One suicide attempt/1357 studied

32 Clonidine Used for ADHD therapy and night sedation
Better for restlessness than attention Useful but popularity waning due to side fx Good for tics and comorbid ADHD Doses 0.05 mg-0.2 mg tds Evening rebound Patch available but import only Care with joint prescribing (ECG recommended) Look out for sedation, hypotension, depression, constipation and dry mouth

33 Clonidine controversy
Clonidine and Methylphenidate 3 case reports of sudden death FDA review decided no causal link Other relevant factors in all cases Clonidine 4 case reports of cardiac arrythmias, one with congenital malformation Use with care if history or family history of collapse. ECG sensible for combination.

34 Guanfacine Possible alternative to Clonidine
Half life of 18 hours in adults 1 open label study and one RCT show efficacy: Scahill et al JAACAP 2001 Spencer et al JAACAP 2009 Similar to clonidine but less sedating, more headaches and insomnia ? Better for attention than hyperactivity Recent licence in US

35 Conclusions Variations in child pharmacokinetics can lead to less predictable responses Requirement of closer monitoring and shared care with parents Many adult approved drugs are given off licence to children Medications have a restricted but important part in holistic care plan Medications are often given symptomatically rather than for diagnosis


Download ppt "Dr Gordon Bates Huntercombe Hospital University of Birmingham"

Similar presentations

Ads by Google