Presentation is loading. Please wait.

Presentation is loading. Please wait.

Pediatric Psychopharmacology Steven Domon, M.D. Laurence Miller, M.D.

Similar presentations


Presentation on theme: "Pediatric Psychopharmacology Steven Domon, M.D. Laurence Miller, M.D."— Presentation transcript:

1 Pediatric Psychopharmacology Steven Domon, M.D. Laurence Miller, M.D.

2 Objectives Review medications used in children for psychiatric indications Review medications used in children for psychiatric indications Discuss levels of evidence for use (“off label vs. FDA-approved) Discuss levels of evidence for use (“off label vs. FDA-approved) Discuss age-specific issues (comorbidity) Discuss age-specific issues (comorbidity) Discuss psychosocial interventions Discuss psychosocial interventions

3 “Off label use” No FDA-approval for a given use No FDA-approval for a given use Very common in pediatrics Very common in pediatrics Not unique to psychiatric medications Not unique to psychiatric medications Often supported by research or other evidence Often supported by research or other evidence Often represents “standard of care” Often represents “standard of care”

4 Stimulants/ADHD Medications As a class, stimulants have among the best evidence of efficacy of any psychotropic As a class, stimulants have among the best evidence of efficacy of any psychotropic All work about equally well All work about equally well Superior to other medications used for ADHD Superior to other medications used for ADHD Strict compliance less important for effect Strict compliance less important for effect Short and long-acting formulations Short and long-acting formulations

5 Stimulants/ADHD Medications (cont.) Side effects: weight loss, insomnia, irritability, cardiac conduction problems Side effects: weight loss, insomnia, irritability, cardiac conduction problems Methylphenidate Methylphenidate Short-acting: Ritalin, Methylin, Focalin Short-acting: Ritalin, Methylin, Focalin Long-acting: Ritalin LA and SR, Metadate ER and CD, Focalin XR, Concerta, Daytrana Patch Long-acting: Ritalin LA and SR, Metadate ER and CD, Focalin XR, Concerta, Daytrana Patch

6 Stimulants/ADHD Medications (cont.) Amphetamines Amphetamines Short-acting: Adderall, Dexedrine, Dextrostat, Desoxyn Short-acting: Adderall, Dexedrine, Dextrostat, Desoxyn Long-acting: Adderall XR, Dexedrine Spansule, Vyvanse Long-acting: Adderall XR, Dexedrine Spansule, Vyvanse

7 Stimulants/ADHD Medications (cont.) Atomoxetine (Strattera): Atomoxetine (Strattera): Mechanism similar to antidepressants Mechanism similar to antidepressants Less effective than stimulants, generally considered second-line except in certain cases Less effective than stimulants, generally considered second-line except in certain cases Less abuse potential Less abuse potential Requires strict compliance to be effective Requires strict compliance to be effective May take weeks to reach effect May take weeks to reach effect

8 Stimulants/ADHD Medications (cont.) FDA approved uses: FDA approved uses: Adderall and Dexedrine age 3 and up Adderall and Dexedrine age 3 and up Others age 6 and up Others age 6 and up Others: Others: Bupropion (Wellbutrin)—and antidepressant Bupropion (Wellbutrin)—and antidepressant Modafanil (Provigil)—for narcolepsy Modafanil (Provigil)—for narcolepsy Clonidine (Catapres)—an antihypertensive Clonidine (Catapres)—an antihypertensive Guanfacine (Tenex)—an antihypertensive Guanfacine (Tenex)—an antihypertensive

9 Antihypertensives Used to treat impulsivity, irritability, disruptive behavior, and aggression Used to treat impulsivity, irritability, disruptive behavior, and aggression Alpha agonists—often used as adjuncts to stimulants: Alpha agonists—often used as adjuncts to stimulants: Clonidine Clonidine Guanfacine Guanfacine Beta Blockers—used more for aggression than as an adjunct to stimulants: Beta Blockers—used more for aggression than as an adjunct to stimulants: Propranolol Propranolol

10 Antidepressants Many classes: tricyclics, MAOIs, SSRIs, SNRIs, others Many classes: tricyclics, MAOIs, SSRIs, SNRIs, others Have been used for a variety of disorders other than depression Have been used for a variety of disorders other than depression All work about equally well but individuals may respond preferentially All work about equally well but individuals may respond preferentially Warnings of suicide may have been overblown Warnings of suicide may have been overblown

11 Monoamine Oxidase Inhibitors (MAOIs) Phenylzine (Nardil), tranylcypromine (Parnate), isocarboxazid (Marplan) Phenylzine (Nardil), tranylcypromine (Parnate), isocarboxazid (Marplan) Rarely used in children due to dietary restrictions and drug interactions. Rarely used in children due to dietary restrictions and drug interactions.

12 Tricyclic Antidepressants (TCAs) With MAOIs, the oldest antidepressants With MAOIs, the oldest antidepressants Imipramine (Tofranil), desipramine (Norpramin), clomipramine (Anafranil), amitriptyline (Elavil), nortriptyline (Pamelor), protriptyline (Vivactil), others Imipramine (Tofranil), desipramine (Norpramin), clomipramine (Anafranil), amitriptyline (Elavil), nortriptyline (Pamelor), protriptyline (Vivactil), others Standard of care for years, now second-line (at best) Standard of care for years, now second-line (at best)

13 TCAs (cont.) Side effects: dry mouth, sedation, constipation, blurred vision, cardiac rhythm effects, very dangerous in overdose Side effects: dry mouth, sedation, constipation, blurred vision, cardiac rhythm effects, very dangerous in overdose FDA-approvals: FDA-approvals: Imipramine—enuresis age 6 and up Imipramine—enuresis age 6 and up Clomipramine—OCD age 6 and up Clomipramine—OCD age 6 and up

14 Selective Serotonin Reuptake Inhibitors (SSRIs) Fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), citalopram (Celexa), escitalopram (Lexapro), fluvoxamine (Luvox) Fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), citalopram (Celexa), escitalopram (Lexapro), fluvoxamine (Luvox) Safer and much better tolerated than MAOIs and TCAs Safer and much better tolerated than MAOIs and TCAs Side effects: GI upset, headaches, sexual dysfunction, somnolence, insomnia, vivid dreams Side effects: GI upset, headaches, sexual dysfunction, somnolence, insomnia, vivid dreams

15 SSRI’s (cont.) FDA indications: FDA indications: Fluoxetine—MDD and OCD age 7 and up Fluoxetine—MDD and OCD age 7 and up Sertraline—OCD age 6 and up Sertraline—OCD age 6 and up Paroxetine—none Paroxetine—none Citalopram—none Citalopram—none Escitalopram—none Escitalopram—none Fluvoxamine—OCD age 6 and up Fluvoxamine—OCD age 6 and up

16 Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) Venlafaxine (Effexor), duloxetine (Cymbalta), trazadone (Desyrel), nefazodone (formerly Serzone) Venlafaxine (Effexor), duloxetine (Cymbalta), trazadone (Desyrel), nefazodone (formerly Serzone) Similar mechanism to SSRIs Similar mechanism to SSRIs Nefazodone—very sedating, risk of liver failure resulted in decreased use Nefazodone—very sedating, risk of liver failure resulted in decreased use FDA approval in children under age 18: none FDA approval in children under age 18: none

17 Other Antidepressants Mirtazipine (Remeron): Mirtazipine (Remeron): Unique mechanism of action Unique mechanism of action Common side effects: sedation, weight gain, headache, vivid dreams Common side effects: sedation, weight gain, headache, vivid dreams No FDA approved pediatric indication No FDA approved pediatric indication Bupropion (Wellbutrin): Bupropion (Wellbutrin): Unique mechanism of action Unique mechanism of action Common side effects: GI upset, may lower seizure threshold Common side effects: GI upset, may lower seizure threshold No FDA approved pediatric indication No FDA approved pediatric indication

18 Antipsychotics Typical: haloperidol (Haldol), chlorpromazine (Thorazine), pimozide (Orap), trifluoperazine (Stelazine), many others Typical: haloperidol (Haldol), chlorpromazine (Thorazine), pimozide (Orap), trifluoperazine (Stelazine), many others Atypical: risperidone (Risperdal), olanzapine (Zyprexa), quetiapine (Seroquel), ziprasidone (Geodon), aripiprazole (Abilify), clozapine (Clozaril) Atypical: risperidone (Risperdal), olanzapine (Zyprexa), quetiapine (Seroquel), ziprasidone (Geodon), aripiprazole (Abilify), clozapine (Clozaril)

19 Typical Antipsychotics Side effects: Side effects: weight gain, sedation, mental slowing, extrapyramidal side effects such as tremors and Parkinson’s-like symptoms, and tardive dyskinesia weight gain, sedation, mental slowing, extrapyramidal side effects such as tremors and Parkinson’s-like symptoms, and tardive dyskinesia FDA-approved pediatric uses FDA-approved pediatric uses Haldol—psychosis ages 3-12 Haldol—psychosis ages 3-12 Thorazine—severe behavior problems, psychosis 6 months-12 yrs Thorazine—severe behavior problems, psychosis 6 months-12 yrs Orap—Tourette’s Syndrome age 12 and up Orap—Tourette’s Syndrome age 12 and up Stelazine—psychosis age 6-12 Stelazine—psychosis age 6-12 Some others are indicated for adolescent psychosis Some others are indicated for adolescent psychosis

20 Atypical Antipsychotics Work on different neurotransmitters Work on different neurotransmitters Once believed to be safer than typical antipsychotics (not necessarily true) Once believed to be safer than typical antipsychotics (not necessarily true) May have diminished risk of tardive dyskinesia when compared to “typical” antipsychotics May have diminished risk of tardive dyskinesia when compared to “typical” antipsychotics Side effects: same as for “typical” antipsychotics. Recently there has been increased attention given to the risk of various metabolic disorders (diabetes, breast milk production) Side effects: same as for “typical” antipsychotics. Recently there has been increased attention given to the risk of various metabolic disorders (diabetes, breast milk production) Often used to treat aggression and disruptive behavior in children and adolescents Often used to treat aggression and disruptive behavior in children and adolescents

21 Atypical Antipsychotics (cont.) FDA-approved uses: FDA-approved uses: Risperdal Risperdal age 5-16 irritability associated with autism age 5-16 irritability associated with autism age bipolar disorder age bipolar disorder age schizophrenia age schizophrenia Abilify Abilify age acute mania or mixed episodes age acute mania or mixed episodes age schizophrenia age schizophrenia Zyprexa—none Zyprexa—none Seroquel—none Seroquel—none Geodon—none Geodon—none Clozaril—none; rarely used in children due to risks of bone marrow suppression Clozaril—none; rarely used in children due to risks of bone marrow suppression

22 Anxiolytics/Sedatives Benzodiazapines Benzodiazapines Diazepam (Valium), lorazepam (Ativan), alprazolam (Xanax), clonazepam (Klonopin), oxazepam (Serax) Diazepam (Valium), lorazepam (Ativan), alprazolam (Xanax), clonazepam (Klonopin), oxazepam (Serax) Significant abuse potential, especially among shorter- acting medications Significant abuse potential, especially among shorter- acting medications Side effects: sedation, disinhibition Side effects: sedation, disinhibition

23 Benzodiazapines FDA approval for anxiety in children: FDA approval for anxiety in children: Valium— for children 6 months and older Valium— for children 6 months and older Ativan—for age 12 and over Ativan—for age 12 and over Xanax—none Xanax—none Klonopin—for seizures in infants and older Klonopin—for seizures in infants and older Serax—for age 6 and over Serax—for age 6 and over

24 Antihistamines Diphenhydramine (Benadryl), hydroxyzine (Vistaril) Diphenhydramine (Benadryl), hydroxyzine (Vistaril) FDA approval: FDA approval: Benadryl—not FDA-approved for anxiety or sedation in children Benadryl—not FDA-approved for anxiety or sedation in children Vistaril—in children for anxiety Vistaril—in children for anxiety Side effects: sedation, dry moth, blurred vision, constipation Side effects: sedation, dry moth, blurred vision, constipation

25 Buspirone (Buspar) Mechanism is different than benzodiazepines Mechanism is different than benzodiazepines Lower abuse potential Lower abuse potential Side effects: insomnia, nervousness, gastrointestinal upset Side effects: insomnia, nervousness, gastrointestinal upset No FDA approval in children No FDA approval in children

26 Other Sedatives Zolpidem (Ambien) Zolpidem (Ambien) Not FDA-approved for children Not FDA-approved for children Eszopiclone (Lunesta) Eszopiclone (Lunesta) Not FDA-approved in children Not FDA-approved in children Trazadone (Desyrel) Trazadone (Desyrel) Antidepressant used sometimes as a sedative Antidepressant used sometimes as a sedative Not FDA-approved in children Not FDA-approved in children

27 Mood Stabilizers Used chiefly to stabilize mood and to diminish aggression Used chiefly to stabilize mood and to diminish aggression Lithium, anticonvulsants, and antipsychotics Lithium, anticonvulsants, and antipsychotics Lithium: Lithium: oldest mood stabilizer oldest mood stabilizer FDA approval in mania for age 12 and over FDA approval in mania for age 12 and over

28 Anticonvulsants Valproate/Valproic acid (Depakote, Depakene) Valproate/Valproic acid (Depakote, Depakene) FDA approval for seizures down to age 10 and for mania in adults FDA approval for seizures down to age 10 and for mania in adults Increased risk of hepatic failure (especially below age 2), pancreatic problems, platelet depression, and weight gain Increased risk of hepatic failure (especially below age 2), pancreatic problems, platelet depression, and weight gain Lamotrigine (Lamictal) Lamotrigine (Lamictal) FDA approval for seizures for ages 2 and above and for Bipolar Disorder in adults FDA approval for seizures for ages 2 and above and for Bipolar Disorder in adults Stevens-Johnson Syndrome Stevens-Johnson Syndrome

29 Anticonvulsants (cont.) Carbemazepine (Tegretol, Carbatrol) Carbemazepine (Tegretol, Carbatrol) no FDA approval for Bipolar D/O regardless of age no FDA approval for Bipolar D/O regardless of age much published data on it’s use as a mood stabilizer much published data on it’s use as a mood stabilizer Stevens-Johnson Syndrome Stevens-Johnson Syndrome Topirimate (Topamax)—no FDA approval for Bipolar D/O regardless of age Topirimate (Topamax)—no FDA approval for Bipolar D/O regardless of age Oxcarbazepine (Trileptal)—no FDA approval for Bipolar D/O regardless of age Oxcarbazepine (Trileptal)—no FDA approval for Bipolar D/O regardless of age Gabapentin (Neurontin)—no FDA approval for Bipolar D/O regardless of age Gabapentin (Neurontin)—no FDA approval for Bipolar D/O regardless of age

30 Antipsychotics as Mood Stabilizers any number of antipsychotics may help stabilize mood, although some are specifically indicated for mood stabilization any number of antipsychotics may help stabilize mood, although some are specifically indicated for mood stabilization Risperdal—age for Bipolar Disorder Risperdal—age for Bipolar Disorder Abilify—age for acute mania or mixed states Abilify—age for acute mania or mixed states

31 Preschoolers Very few agents are currently FDA-approved for psychiatric use in preschoolers. Very few agents are currently FDA-approved for psychiatric use in preschoolers. Preschool Psychopharmacology Working Group (Gleason, et al., JAACAP, 46:12, December 2007) Preschool Psychopharmacology Working Group (Gleason, et al., JAACAP, 46:12, December 2007) Developed algorithms for a variety of disorders Developed algorithms for a variety of disorders Emphasized the importance of psychosocial interventions before medications are utilized in part to better support the development of emotional and behavioral self-regulation Emphasized the importance of psychosocial interventions before medications are utilized in part to better support the development of emotional and behavioral self-regulation Medication recommendations, when made, are secondary to psychosocial interventions Medication recommendations, when made, are secondary to psychosocial interventions

32 Adolescents Often approached from a treatment standpoint as “little adults,” but it is not that simple. Often approached from a treatment standpoint as “little adults,” but it is not that simple. Substance abuse often becomes a factor Substance abuse often becomes a factor May lead to other psychiatric problems May lead to other psychiatric problems Other psychiatric problems may lead to substance abuse Other psychiatric problems may lead to substance abuse Sometimes give away or sell their psychiatric medications Sometimes give away or sell their psychiatric medications

33 Psychosocial Interventions Variety of interventions—individual, family, group, etc. Variety of interventions—individual, family, group, etc. Multitude of techniques—psychoeducational, supportive, psychodynamic, cognitive, behavioral, etc. Multitude of techniques—psychoeducational, supportive, psychodynamic, cognitive, behavioral, etc. Many techniques are highly therapist dependent Many techniques are highly therapist dependent Not all “therapy” is equal Not all “therapy” is equal Some geographic areas are often underserved Some geographic areas are often underserved Lack of psychosocial intervention availability may result in higher rates of medication use Lack of psychosocial intervention availability may result in higher rates of medication use


Download ppt "Pediatric Psychopharmacology Steven Domon, M.D. Laurence Miller, M.D."

Similar presentations


Ads by Google