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Download Update on Medications for Individuals with Autism Spectrum Disorder
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11/11/2014 Update on Medications for Individuals with Autism Spectrum Disorder Debra Stevens, PharmD, BCPP Director of Pharmacy Services DHS/Developmental Disabilities Services Objectives 1. Discuss the most common psychotropic medications utilized to manage behavioral issues associated with autism. 2. Identify the most important questions to ask before and after a psychotropic medication is prescribed. 3. Describe potential environmental and medical causes for behavioral challenges in individuals with autism. Psychotropic Medications FDA approved Risperdal (risperidone) – approved for irritability associated with autism in those age 5-17 Abilify (aripiprazole) – approved for irritability associated with autism in those age 6-17 1 11/11/2014 Other medications utilized Other atypical antipsychotics Stimulants Alpha-2 agonists (clonidine, guanfacine) SSRIs Anticonvulsants (carbamazepine, divalproex) Melatonin Antipsychotics May be useful with irritability, aggression, self injury, hyperactivity, and repetitive behavior. Side effects – sedation, extrapyramidal symptoms, weight gain and metabolic side effects, tardive dyskinesia Antipsychotics Risperdal (risperidone) Clozapine, FazaClo (clozapine) Abilify (aripiprazole) Seroquel (quetiapine) Zyprexa (olanzapine) Fanapt (iloperidone) Invega (paliperidone) Saphris (asenapine) Geodon (ziprasidone) Older antipsychotics – Haldol (haloperidol) Latuda (lurasidone) 2 11/11/2014 Stimulants May be helpful for ADHD symptoms (hyperactivity, inattention, impulsiveness). Side effects may be more common in those with autism spectrum disorder. Appear to have increased risk of causing irritability in those with ASD. Stimulants Examples: Ritalin, Metadate, Concerta, (methylphenidate) Dexedrine (dextroamphetamine) Adderall (amphetamine/ dextroamphetamine) Strattera (atomoxetine) Alternative to stimulants Effects not immediate Some small studies have shown improvement in hyperactivity, inattention, and irritability in children with ASD. 3 11/11/2014 Alpha-2 Agonists May reduce irritability, hyperactivity, inattention, and impulsivity. Another alternative to stimulant use Side effects – drowsiness, low blood pressure Alpha-2 Agonists Examples: Catapres (clonidine) Tenex, Intuniv (guanfacine) – currently a trial underway examining the use of Intuniv to treat hyperactivity in children age 5-17 with ASD. Anticonvulsants May be helpful with irritability, aggression, mood lability, and impulsivity. May be considered, particularly if the individual also has seizures. 4 11/11/2014 Anticonvulsants Examples: Depakote (divalproex) Depakene (valproic acid) Tegretol (carbamazepine) Trileptal (oxcarbazepine) Lamictal (lamotrigine) Topamax (topiramate) Selective Serotonin Reuptake Inhibitors (SSRI antidepressants) May be useful for treating anxiety, depression, compulsions, and repetitive behaviors in those with ASD. Individuals with ASD may be more likely to have behavioral activation and aggression associated with SSRI use. SSRIs Prozac (fluoxetine) Zoloft (sertraline) Paxil (paroxetine) Luvox (fluvoxamine) Celexa (citalopram) Lexapro (escitalopram) 5 11/11/2014 Melatonin May be helpful to manage sleep disorders in those with ASD. Questions to ask the physician Before a medication is prescribed After a medication is prescribed Before medication is prescribed… Has there been an appropriate diagnostic evaluation? What non-medication strategies have been consistently implemented? Target symptoms must be identified in the initial assessment! Long-term? Acute? Episodic? 6 11/11/2014 Before medication is prescribed… Have potential causes for “behaviors” been ruled out? Drug-related Correlation between escalation and a change in medication? Side effects of medication may lead to behavioral difficulties, particularly in those unable to verbalize! Potential Causes - Medical If a medical issue causing difficulties is not addressed, the behavior WILL NOT get better! Behavioral Causes or Influences Physiological Environmental Psychological Social 7 11/11/2014 Physiological Causes • Allergies • Arthritis • Constipation • Ear aches • Fractures • Hunger • Visual/hearing impairment • Thirst • Seizures • Premenstrual syndrome • Pain • Headaches • Medication reactions/side effects • Dental Environmental Causes Proximity to others Humidity Uncomfortable furniture Temperature Smells Limited physical space Lighting Noise Psychological Causes Anxiety Loneliness Attitudes Phobias Beliefs Personality traits Boredom Shyness Dominance Submissiveness Fear Suspiciousness Worry Vengeance 8 11/11/2014 Social Causes Change in caregivers Criticism Danger Lack of social attention Not having choices Demands Presence of a specific person (s) Disapproval Relocation Disruption Teasing by others Frequent change Tone of voice Too little or too much to do Power struggles What does the doctor really need to know? What is going on? When is it occurring? What is going on in the environment when behavior difficulties occur? Bring data and tracking sheets Before medication is prescribed… What behavioral strategies will be implemented in combination with psychotropic medication? What is the goal of treatment? What are the criteria for dose reduction/discontinuation? 9 11/11/2014 While psychotropic medications are an intervention, they are also a problem! Psychotropic Polypharmacy Increased risk of: Adverse drug reactions and the severity of those reactions Drug-to-drug interactions Cumulative toxicity Medication errors Non-compliance Morbidity and mortality Behavior Monitoring “the most underutilized and/or poorly implemented component of the psychotropic drug monitoring process.” If the doctor prescribed a medication to treat blood pressure, you would expect them to monitor your blood pressure! 10 11/11/2014 After medication is prescribed How will I know the medication is working? What target symptoms is the medication prescribed for? When should I expect a medication response? What are the main side effects? What should be monitored with medication use? Rule of Thumb with New Behavioral Difficulties Always examine environmental changes. Always determine if there have been recent medication changes to rule out medication toxicity/side effects. Always rule out medical issues. Rapid/multiple medication changes are likely to be counterproductive and may confuse the picture. Use of Medications Start low and go slow! Individuals with ASD may be more sensitive to side effects and to changes in therapy. 11 11/11/2014 Questions? 12
