Pediatric Psychopharmacology - PowerPoint PPT Presentation

1 / 33
About This Presentation
Title:

Pediatric Psychopharmacology

Description:

Discuss levels of evidence for use ('off label vs. FDA-approved) ... Warnings of suicide may have been overblown. Monoamine Oxidase Inhibitors (MAOIs) ... – PowerPoint PPT presentation

Number of Views:198
Avg rating:3.0/5.0
Slides: 34
Provided by: steved151
Category:

less

Transcript and Presenter's Notes

Title: Pediatric Psychopharmacology


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

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

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

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

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

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

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

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

9
Antihypertensives
  • Used to treat impulsivity, irritability,
    disruptive behavior, and aggression
  • Alpha agonistsoften used as adjuncts to
    stimulants
  • Clonidine
  • Guanfacine
  • Beta Blockersused more for aggression than as an
    adjunct to stimulants
  • Propranolol

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

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

12
Tricyclic Antidepressants (TCAs)
  • With MAOIs, the oldest antidepressants
  • Imipramine (Tofranil), desipramine (Norpramin),
    clomipramine (Anafranil), amitriptyline (Elavil),
    nortriptyline (Pamelor), protriptyline
    (Vivactil), others
  • 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
  • FDA-approvals
  • Imipramineenuresis age 6 and up
  • ClomipramineOCD age 6 and up

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

15
SSRIs (cont.)
  • FDA indications
  • FluoxetineMDD and OCD age 7 and up
  • SertralineOCD age 6 and up
  • Paroxetinenone
  • Citalopramnone
  • Escitalopramnone
  • FluvoxamineOCD age 6 and up

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

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

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

19
Typical Antipsychotics
  • Side effects
  • weight gain, sedation, mental slowing,
    extrapyramidal side effects such as tremors and
    Parkinsons-like symptoms, and tardive dyskinesia
  • FDA-approved pediatric uses
  • Haldolpsychosis ages 3-12
  • Thorazinesevere behavior problems, psychosis 6
    months-12 yrs
  • OrapTourettes Syndrome age 12 and up
  • Stelazinepsychosis age 6-12
  • Some others are indicated for adolescent
    psychosis

20
Atypical Antipsychotics
  • Work on different neurotransmitters
  • Once believed to be safer than typical
    antipsychotics (not necessarily true)
  • 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)
  • Often used to treat aggression and disruptive
    behavior in children and adolescents

21
Atypical Antipsychotics (cont.)
  • FDA-approved uses
  • Risperdal
  • age 5-16 irritability associated with autism
  • age 10-17 bipolar disorder
  • age 13-17 schizophrenia
  • Abilify
  • age 10-17 acute mania or mixed episodes
  • age 13-17 schizophrenia
  • Zyprexanone
  • Seroquelnone
  • Geodonnone
  • Clozarilnone rarely used in children due to
    risks of bone marrow suppression

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

23
Benzodiazapines
  • FDA approval for anxiety in children
  • Valium for children 6 months and older
  • Ativanfor age 12 and over
  • Xanaxnone
  • Klonopinfor seizures in infants and older
  • Seraxfor age 6 and over

24
Antihistamines
  • Diphenhydramine (Benadryl), hydroxyzine
    (Vistaril)
  • FDA approval
  • Benadrylnot FDA-approved for anxiety or sedation
    in children
  • Vistarilin children for anxiety
  • Side effects sedation, dry moth, blurred vision,
    constipation

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

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

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

28
Anticonvulsants
  • Valproate/Valproic acid (Depakote, Depakene)
  • 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
  • Lamotrigine (Lamictal)
  • FDA approval for seizures for ages 2 and above
    and for Bipolar Disorder in adults
  • Stevens-Johnson Syndrome

29
Anticonvulsants (cont.)
  • Carbemazepine (Tegretol, Carbatrol)
  • no FDA approval for Bipolar D/O regardless of age
  • much published data on its use as a mood
    stabilizer
  • Stevens-Johnson Syndrome
  • Topirimate (Topamax)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

30
Antipsychotics as Mood Stabilizers
  • any number of antipsychotics may help stabilize
    mood, although some are specifically indicated
    for mood stabilization
  • Risperdalage 10-17 for Bipolar Disorder
  • Abilifyage 10-17 for acute mania or mixed states

31
Preschoolers
  • Very few agents are currently FDA-approved for
    psychiatric use in preschoolers.
  • Preschool Psychopharmacology Working Group
    (Gleason, et al., JAACAP, 4612, December 2007)
  • 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
  • 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.
  • Substance abuse often becomes a factor
  • May lead to other psychiatric problems
  • Other psychiatric problems may lead to substance
    abuse
  • Sometimes give away or sell their psychiatric
    medications

33
Psychosocial Interventions
  • Variety of interventionsindividual, family,
    group, etc.
  • Multitude of techniquespsychoeducational,
    supportive, psychodynamic, cognitive, behavioral,
    etc.
  • Many techniques are highly therapist dependent
  • Not all therapy is equal
  • Some geographic areas are often underserved
  • Lack of psychosocial intervention availability
    may result in higher rates of medication use
Write a Comment
User Comments (0)
About PowerShow.com