Download The role of polypharmacy in children with developmental

The role of polypharmacy in
children with developmental
disability: Art or science
Natalie Silove
CHW
Case Study
• Simon 13 year old
• Severe Autism, Intellectual disability
Non verbal
• Normal perinatal history
• Autism and DD diagnosed by 3 years
• ABA started 30 hours a week
• CAM +++
• First consult at age 8 years old
• Severe hyperactivity impulsivity no
concentration
• Very obsessive water play, light flicking
• Lots of stereotypies
• Head banging rocking,
• Throwing, biting, hitting
• Vision hearing ok
• Recurrent episodes of vomiting , ear
infections, bleeding nose, ears, over many
years
MEDICATIONS TRIALED:
• Fluoxetine ( lovan) caused increased
aggression/agitation/ stopped
• Fluvoxamine 25mg mane 50mg nocte – helpful
for 18 m and then esclating aggression)
• Methylphenidate/dexamphetamine no
improvement ceased
• Introduced Endep ( amitriptyline)helpful,
• Carbamazepine ( very helpful) ceased due to
rash after adequate trial
• Risperidone initially helpful ceased due
increased appetite and weight aripiprazole
started
• Diazepam ceased due to tolerance
Current medications
– Rabeprazole (Pariet®) one tablet nocet
– Naltrexone (50mg tablet)1/2 tablet BD
– Clonidine ( 100ug )1/2 tablet m, lunch and 1
nocte
– Aripriprazole(10mg tablet) ½ TDS
– Amitriptyline 25mgTDS
NB:
medical/psych/communication/sensory/OT/beha
vioural/parenting/social support/referrals etc
Social History
• Simon is the oldest of two children of Australian Couple.
Father in IT and Mother RN
• Happy marriage, no primary health or mental health
problems
• Mother stopped work to ensure adequate intervention and
support in early years and to maximise ABA, went back to
work when Simon at school
• Changed schools four times
• Stopped work again when school could not cope with
behaviour – tried home school, with ABA and ADHC
support
• Mother became more isolated, put on weight,
sleep affected diagnosed with depression ,
refused medication and respite
• Aggression directed to mum, accepted
overnight respite provided for two nights every
3-6 months, but respite would call parents and
they would have to pick him because
aggression
• Mother hospitalised for depression and suicidal
behaviours – emergency services brought in to
the home, constant changing of carers ,
medication crises wrong doses, duplication of
doses etc
• Mother came out of hospital, managed for
another 2 years, strongly proactive, compliant,
trying to work with services, but
• Remained on waiting lists for over 18m, then
assessment, then therapist would leave, no
services, position empty, then someone
employed, then maternity leave, never had one
therapist for more than two sessions and had
repeated needs assessments and no therapy.
• Therapists did not visit the schools, only the
home
• Constant behavioural ‘emergencies’ which
resulted in suspensions
• Parents more stressed, other son
moved to public school, all his activities
stopped due to financial constraints,
father depressed, staying at work longer
and longer, family socially isolated, and
eventually mum took S to police station
, caught a plane to the Philippines and
refused to come back until he was
placed in out of home care.
• S in full time out of home care
• Parents moved to a smaller house
• Parents have retained guardianship and
visit s regularly
• Brother off all SSRI medication despite
having been diagnosed with atypical
autism
• Mum back at work
• Family just been for the first holiday in 13
years!
Ethical Issues:
• ? Medication plugging the hole for
psychosocial services
• ? Medication used as a quick fix
because psychosocial intervention
takes time
• ? Machine gun or pharmacologically
rich approach
• ? Threw baby out with water
• In home vs out of home
Polypharmacy
Literature says polypharmacy leads to: Increase in drug interactions
Decrease in adherence
Adverse outcomes for patient
“the use of therapeutic agents represents a
trade off between benefits of symptoms relief
or disease modification that increase quality
of life and the risk of short and long term
adverse effects”1
1. Morden and Goodman 2011
Archped
5HT2C
DRI
m-ACh
NRI
SRI
NOS
SSRI
1A2
CYP 2D6
6-40
CYP 3A4
Stahl S M, Essential13
Psychopharmacology (2000)
Drug cocktails
•
•
•
•
Pharmacological rich
Multireceptor focus
Individualised medication
Potential for drug interactions both
pharmacodynamic and pharmacokinetic
mechanism
When serotonin receptor blockade added
When noradrenaline blockade is
added
Summary of receptors and adverse effects
drug
receptor
Common adverse and positive effect
amitriptyline
1
hypotension
Mu
Constipation, thirst, blurred vision
SERT
Bleeding, platelet aggregation
NERT
‘pseudoanticholinergic’ dry mouth, constipation, urinary retention
5HT2C
Increase satiety, weight gain
5HT
Agitation initially, nausea initially,

Hypotension, respiratory effects
H1
Weight gain, drowsiness
clonidine
2 3
Drowsiness, hypotension
aripiprazole
D2
Extrapyramidal effects, hyperprolactinemia
5HT2A
Decrease positive symptomology
5HT1A
Cortical pyramidal neuron, regulates hormones -post synaptic, decreases
dopamine release – presynaptic autoreceptor
D3
?cognitive effects
Practical approach to Medication
Setting the stage:
• Understand family context background,
views, prejudices, myths
• Parents need context, information, time,
reactions may vary from angry, denial,
guilt, pragmatic acceptance, relief
• Family issue, not a patient/client issue
• Medication always one part of a
holistic/multidisciplinary plan
Considerations: social
•
•
•
•
•
•
•
Is there a responsible primary carer
Mental health issues in parents
Parental medication history
Substance abuse
Divorce
Extended family /friends views
Media/internet influence
Medical
• Provide rationale ( working diagnosis) and
information
• Provide sufficient time for discussion
• Opportunity to review and discuss again
• Respectful of parents decision
• Informed Consent clearly documented
• Start low and go slow
• Clear written schedule
• Available for consultation during trial
• Monitoring benefits and side effects
• Emphasise that medication is not forever
• Discuss how medication would be stopped and what
would be the best times to do this
Summary
• Multi disciplinary
• Multi settings
• Consistent team approach. No one discipline
has the magic bullet.
• Communication between the team members
• Medication and at times Polypharmacy has a
valuable role in complex behavioural disorders
• Thorough assessment required
• Targeted behaviour monitored closely/constant
review
• Family focussed intervention