Psychotropic Medication for Children and Adolescents. Contents

Transcription

1 Contents ADHD Medications... 2 Tricyclic Antidepressants... 3 Monoamine Oxidase Inhibitors... 4 Serotonergic Antidepressants... 5 Other Antidepressants... 6 Mood Stabilizer (Lithium)... 8 Mood Stabilizer (Anticonvulsants)... 9 Anxiolytic Alpha-Adrenergic Agents Conventional (Older) Antipsychotics Atypical (Newer) Antipsychotics Anticholinergic/Antiparkinson and Antihistamine Beta-Adrenergic Blocker Opiate Blocker Hypnotic References Page 1 of 20

2 ADHD Medications Stimulants Amphetamine Salts (Adderall, Adderall XR) Dextroamphetamine (Dexedrine) Lisdexamfetamine (Vyvanse) Dexmethylphenidate (Focalin Focalin XR) Methylphenidate (Concerta, Daytrana, Metadate, Metadate ER, Metadate CD, Methylin, Methylin ER, Ritalin, Ritalin SR, Ritalin LA,) Attention Deficit/ Hyperactivity Disorder ADHD Attention deficit symptoms associated with other mental disorders mg/kg/d (40 mg/d) (Amphetamine salts, Dextroamphetamine) mg/d (Lisdexamfetamine) 0.5 mg/kg/d (20 mg/d) (Dexmethylphenidate) 30 mg/day (Daytrana patch) mg/kg/d (72 mg/d) (Methylphenidate) Insomnia, decreased appetite, weight loss, delayed growth Depression Psychosis (rare, with very high doses) Increase in heart rate and blood pressure (mild), Withdrawal effects and rebound phenomena Rarely, tic disorders Dyskinetic movements/tics possible Exacerbation of obsessions and compulsions Agitation, irritability Psychosis & breast feeding Simultaneous treatment with MAO inhibitors Alcohol or drug abuse Anorexia nervosa Severe anxiety Cardiac/blood pressure anomalies (if significant, request cardiology consultation) Family/personal history of Tourette s (if necessary, consider other medications) Thyroid disease Glaucoma but with special attention paid to heart rate (HR), blood pressure (BP), height, weight, and dyskinetic movement inventory If appropriate, cardiology consultation (see column 5) Repeat height, weight, BP, and HR, and dyskinesia check every 6 months laboratory (chemistry panel, CBC + differential, TSH, urinalysis); other lab, as One-three times Atomoxetine (Strattera) ADHD Attention deficit symptoms associated with other mental disorders mg/kg/d (100 mg/d) Once or twice Same as above, plus Abnormal liver function tests Chemical hepatitis (rare) As above plus Contraindication History of impaired liver functioning As above plus Baseline liver function tests (LFT s), and chemistry panel. Repeat LFT s every 6 months Page 2 of 20

3 Tricyclic Antidepressants Antidepressants Tricyclics Desipramine (Norpramin, Pertofrane) Imipramine (Tofranil) Nortriptyline (Pamelor) Enuresis Tic disorders ADHD: If psychostimulants and/or other medications are not effective mg/kg/d ( mg/d) ( mg/kg/d for Nortriptyline, mg/d) Dose adjusted according to serum levels (therapeutic window for Nortriptyline) mg/kg/d ( mg/d) (Imipramine) for enuresis 1-4 x/d Anticholinergic [dry mouth, constipation, blurred vision, urinary retention, confusion (higher doses)] Change in weight Cardiovascular (mild blood pressure and ECG conduction parameters with daily doses >3.5 mg/kg) Psychosis, mania, delirium Flu-like withdrawal syndrome (Cholinergic rebound) Decreased seizure threshold Sedation, dizziness syncope When medication administered once daily, younger minors may show daily withdrawal effects ECG changes Narrow angle glaucoma Co-administration with MAO inhibitor Uncontrolled seizure disorder & breast feeding Thyroid dysfunction (can cause cardiac arrhythmias) Psychosis May increase the risk for developing future episodes of manic behavior Overdose may be lethal with special attention paid to heart rate (HR), blood pressure (BP), height, weight, plus a thyroid panel, a baseline ECG, and a thorough substance abuse history in order to determine potential interactions between tricyclics and substances of abuse (When low doses of Imipramine are prescribed for enuresis, a baseline ECG is necessary, only if ) Ongoing serum levels, if ECG/vital sign monitoring: after each increase in dose when doses are >3mg/kg/day, then repeat ECG, BP, and HR Laboratory (chemistry panel, CBC + differential, TSH, urinalysis); other lab, as Clomipramine (Anafranil) Same as Tricyclics plus OCD mg/kg/d ( mg/d) Same as Tricyclics Same as Tricyclics Same as Tricyclics 1-4 x/d Page 3 of 20

4 Monoamine Oxidase Inhibitors Monoamine oxidase inhibitors (MAOI) antidepressants 1. Isocarboxazide (Marplan) 2. Phenelzine (Nardil) 3. Tranylcypromine (Parnate) Atypical depression, refractory mg/kg/d mg/d mg/d mg/d 1-4 x/d Severe dietary restrictions (high tyramine foods) Hypertensive crisis with dietetic transgression or with certain drugs Weight gain Drowsiness Changes in blood pressure Insomnia Liver toxicity (remote) Headache or chest pain Sedation, dizziness, syncope Psychosis, mania, delirium, confusion Liver failure Abnormal blood pressure Risk of pregnancy Risk for poor treatment compliance Co-administration of SSRI s, other serotonergic agents, or other antidepressants Co-administration of Dextromethorphan, Dopaminergics, Sympathomimetics, Reserpine, Psychostimulants, Meperidine laboratory; other lab, as Not recommended with CYS patient population, except as a last resort and only after consultation with two independent child psychiatrists Page 4 of 20

5 Serotonergic Antidepressants Selective Serotonin Reuptake Inhibitors (SSRI s) 1. Fluoxetine (Prozac) 2. Sertraline (Zoloft) 3. Paroxetine (Paxil) 4. Fluvoxamine (Luvox) 5. Citalopram (Celexa) 6. Escitalopram (Lexapro) Anxiety disorders Depressive disorders Obsessive Compulsive Disorder Eating disorders Impulsive aggression mg/kg/d (1-80 mg/d) mg/kg/d (1-200 mg/d) (1-60 mg /d) mg/kg/d ( mg/d) mg/d mg/d Once daily except for Luvox With Luvox, twice per day if dose greater than 100 mg/day Can take six to eight weeks for a clinical response CNS excitation (mania, pressured speech, subjective feelings of excitement, restlessness, transient psychoses) Excess sweating Weight loss or gain Irritability Insomnia GI symptoms (usually transient) Headaches Neuromuscular restlessness (may respond to a benzodiazepine) Behavioral side effects (Motoric and behavioral activation, pervasive silliness, insomnia, an internal feeling of excitation, social inhibition, socially intrusive or obnoxious behavior, and possibly suicidal ideation) Co-administration of an MAO inhibitor Co-administration of Tryptophan or Astemizole (Hismanal) Co-administration of heterocyclics, lithium History of seizures (may lower seizure threshold) Co-administration with Trazodone (may cause cognitive dulling) Co-administration with many other drugs (requires familiarity with PDR) Delayed withdrawal effects (Because of delay in onset as well as much variability and multiplicity of effects, withdrawal side effects should not be mistaken as a return of, and/or the start of a new emotional illness) Co-administration of Terfenadine (Seldane) laboratory; other lab, as Page 5 of 20

6 Other Antidepressants Bupropion (Wellbutrin) Bupropion SR (Wellbutrin SR) Bupropion XL (Wellbutrin XL) ADHD Depression 3-6 mg/kg/d ( mg/d) For regular Wellbutrin and Wellbutrin SR: to minimize the incidence of seizures, daily dose should not exceed 450 mg; no individual dose greater than 150 mg; 150 mg doses should be given more than six hours apart. Drug-induced seizures (in doses > 6 mg/kg) Agitation, irritability, restlessness Headache, insomnia, nausea, upper respiratory complaints, tremors, constipation Allergic skin rash. May aggravate preexisting tics May cause weight loss Co-administration of MAOI s Seizure disorder History of eating disorder (increased seizure risk) History of head trauma, CNS tumor or other organic brain disease (higher risk of seizures) Recent withdrawal from benzodiazepines or alcohol with special lab attention paid to liver, and kidney status; i.e. LFT, renal function tests (BUN, creatinine) Baseline screen for movement disorders, including tics laboratory; other lab as 1-3 x/d EEG abnormalities (consultation with neurologist needed) Hepatic or renal disease (potential for drug to accumulate in body) Co-administration of psychotropics known to lower seizure threshold History of substance abuse Comorbid ADHD and Tourette s Syndrome Co-administration with other anti depressants, lithium (increased seizure risk) Mirtazapine (Remeron) Depression mg/d 1 x/d Rare agranulocytosis Sedation Dizziness Headaches Weight gain Co-administration of an MAO inhibitor laboratory; other lab as Page 6 of 20

7 Other Antidepressants (continued) Trazadone (Desyrel) Insomnia Aggression Depression Anxiety 2-6 mg/kg/d ( mg/d) 1-3 x/d Orthostatic hypotension (take with meals to slow absorption) Priapism (incidence in adults, about 1:15,000; incidence in children not known) Sedation Dizziness Headaches Potentiates effect of CNS depressants Co-administration of an MAO inhibitor Co-administration of an antihypertensive (may cause severe hypotension) Do not use with Terfenadine (Seldane) or Astemizole (Hismanal) laboratory; other lab as Venlafaxine (Effexor, Effexor XR) Depression Anxiety mg/d Effexor mg/d Effexor XR 1-4 x/d Sustained hypertension Sedation Dizziness Headaches, Third Trimester Co-administration of an MAO inhibitor laboratory; other lab as Page 7 of 20

8 Mood Stabilizer (Lithium) Antimanic agents Lithium Carbonate (Eskalith, Lithane) Lithium Citrate (Cibalith-S) Bipolar disorder, manic Prophylaxis of bipolar disorder Adjunct treatment in refractory MDD or schizoaffective disorder Schizoaffective disorder Impulsive aggression mg/kg/d, dose adjusted with serum levels 1500 mg/d for children and 2100 mg/d for adolescents Two to four times Nausea, vomiting, diarrhea Fine Tremor (unresponsive to anti-parkinson drugs) Leukocytosis Malaise and fatigue Weight gain Polyuria and polydipsia Skin abnormalities Drowsiness Change in thyroid and renal function Diabetes (uncommon) Possible disturbance in bone growth and development Hair loss (rare) NMS, when co-administered with an antipsychotic (rare) Overdose/toxicity (ataxia, dysarthria, gross tremor, delirium, hallucinations, seizure, confusion, stupor) Renal/cardiovascular disease BUN higher than 50 Serum Creatinine level greater than 1.5 Use of diuretic medication Salt free diet Severe dehydration/sodium depletion Thyroid disease (endocrine consultation needed) Patient on diuretics Physical and routine lab: CBC + differential, chemistry panel, UA, plus thyroid panel; creatinine level, ECG, dyskinesia evaluation; Medical follow-up: on-going dyskinesia check, weight and BP monitoring Maintenance serum levels for children over 12 should be between 0.6 to 1.2 meq/l Check levels 5-7 days after each change in dosage During first four months check levels monthly, thereafter at least bi-monthly, more frequently if psychopathology and side effects change TSH, electrolytes and serum creatinine levels should be repeated every six months ECG annually (or as ) On-going pregnancy tests, as laboratory; other lab as Page 8 of 20

9 Mood Stabilizer (Anticonvulsants) Carbamazepine (Tegretol) Bipolar disorder, manic Prophylaxis of bipolar disorder Adjunct treatment in refractory MDD or schizoaffective disorder Schizoaffective disorder Dysphoria and impulsive Aggression Seizure disorder Trigeminal neuralgia mg/kg/d, dose adjusted with serum levels 1200 mg/d 2-4 x/d Diplopia Bone marrow suppression (rare) Dizziness, drowsiness nausea and vomiting Syncope, ataxia Dysarthria Leukopenia (usually non progressive) Skin rashes EKG changes Liver toxicity (uncommon) LFT abnormalities (induces liver enzymes) Increased hepatic metabolism, especially estrogen /hypersensitivity to Tricyclics History of bone marrow suppression Use of MAOI in last 2 weeks History of glaucoma or Sjogren s disease, liver or renal disease, or Cardiovascular abnormalities: MI in last 6 weeks or history of severe high or low blood pressure plus ECG, chemistry panel, including hepatic enzymes, thyroid panel, platelet count; Maintenance serum level range is 4-12 µg/ml Ongoing serum levels; CBC + differential and liver enzymes every three months or more frequently if rash, sore throat or fever occurs ECG at therapeutic blood levels; thereafter as laboratory; other lab as Page 9 of 20

10 Mood Stabilizer (Anticonvulsants) - continued Valproic acid (Depakene) Divalproex sodium (Depakote, Depakote ER) Bipolar disorder, manic Prophylaxis of bipolar disorder Adjunct treatment in refractory MDD or schizoaffective disorder Schizoaffective disorder Impulsive aggression Seizure disorder mg/kg/d, dose adjusted with serum levels = µg/ml (optimal blood draw time for Depakote is 12 hours post dose, for Depakote ER hours post dose) 1-4 x/d GI (nausea, vomiting, indigestion, usually transient) Increased appetite/weight gain LFT dose related abnormalities (commonly transient and/or non progressive) Tremor (dose related) Sedation (common with polypharmacy) Ataxia Rash Polycystic ovary disease Fatal pancreatitis Hair loss (uncommon and reversible) Blood dyscrasia (uncommon) (Early) hepatic failure (rare, and then usually in children less than age three) History of bone marrow suppression/liver disease Congenital metabolic disorders & Breast feeding Aspirin (or other drugs affecting coagulation) Age < 2 y/o Co administration with CNS Depressants Risk of Stevens-Johnson Syndrome (chemistry panel, CBC + differential, UA) plus platelet coagulation studies Therapeutic serum level range is µg/ml (15-30 mg/kg/d) Serum level 5-7 days after dose change Every three months: CBC + differential, liver enzymes and coagulation studies Except initially, liver enzymes monthly, for the first six months laboratory; other lab, as Page 10 of 20

11 Mood Stabilizer (Anticonvulsants) - continued 1. Gabapentin (Neurontin) 1. Bipolar disorder Adjunct treatment in refractory MDD or schizoaffective disorder Schizoaffective disorder Impulsive aggression Seizure disorder mg/d 1-3 x/d Lethargy, stupor, confusion delirium, weight gain Allergy to the drug and breast feeding Liver disease Physical and routine lab: CBC + differential, chemistry panel, UA, plus thyroid panel 2. Lamotrigine (Lamictal) 2. Bipolar disorder, manic Prophylaxis of bipolar disorder Adjunct treatment in refractory MDD or schizoaffective disorder Schizoaffective disorder Impulsive aggression Seizure disorder mg/d (over 12 years old) 200 mg/d (under 12 years old) Lethargy, stupor, confusion delirium, but not weight gain Allergy to the drug and breast feeding Liver disease Risk of Stevens-Johnson Syndrome Physical and routine lab: CBC + differential, chemistry panel, UA, plus thyroid panel 1-3 x/d 3. Oxcarbazepine (Trileptal) 3. Bipolar disorder, manic Prophylaxis of bipolar disorder Adjunct treatment in refractory MDD or schizoaffective disorder Schizoaffective disorder Impulsive aggression Seizure disorder 3. / See PDR (complex dosage schedule) Lethargy, stupor, confusion delirium, weight gain Hyponatremia Allergy to the drug and breast feeding Liver disease Hypersensitivity to carbamazepine Risk of Stevens-Johnson Syndrome Physical and routine lab: CBC + differential, chemistry panel, UA, plus thyroid panel Periodic CBC and electrolytes 4. Topiramate (Topamax) 4. Bipolar disorder, manic Prophylaxis of bipolar disorder Adjunct treatment in refractory MDD or schizoaffective disorder Schizoaffective disorder Impulsive aggression Seizure disorder mg/kg/d 2 x/d Lethargy, stupor, confusion delirium, but not weight gain Hyperthermia Oligohydrosis Hyperchloremic acidosis Cognitive dulling Page 11 of 20

12 Anxiolytic Antianxiety drugs High potency Benzodiazepines Clonazepam (long-acting) (Klonopin) Long Acting Effect Short-term relief of anxiety and some sleep disorders (severe) Adjunct in treatment of refractory psychosis (rare) Adjunct in treatment of refractory mania (rare) Older adolescents: severe agitation, muscle relaxation, sleep disorders (severe) Younger children: night terrors, somnambulism mg/kg/d ( mg/d) One to two times per day CNS Depression: Fatigue, drowsiness, ataxia, confusion respiratory depression Incoordination, slurred speech, diplopia, tremor Dyscontrol, disinhibition, excitation, increased anxiety, increased aggression Rage reaction, hallucinations, insomnia, nightmares Rebound and withdrawal reactions Potential risk for abuse and dependence / Acute narrow angle glaucoma or risk of pregnancy Co-morbid substance abuse or dependency Effect potentiated by: phenothiazines, opiates, barbiturates, MAOI s, TCA s, cimedtidine Potentiates effects of: hypnotics, sedatives, alcohol Half-life extended by: renal disease, liver disease, oral contraceptives, cimedtidine, obesity Initial and annual physical with laboratory examination: CBC + differential and chemistry panel Alprazolam (Xanax) Same as Clonazepam, but short acting (may have antidepressant effect in adults) mg/kg/d ( mg/d) Similar to Clonazepam, but: Higher risk for rebound and withdrawal reactions Similar to Clonazepam Similar to Clonazepam Three to four times per day Lorazepam (Ativan) Same as Clonazepam, but short acting Temporary use in severe adjustment disorder with anxious mood and agitation mg/kg/d ( mg/d) Similar to Clonazepam, but: Higher risk for rebound and withdrawal reactions Similar to Clonazepam Similar to Clonazepam Three to four times per day Page 12 of 20

13 Anxiolytic (continued) Atypical anxiolytic Buspirone (BuSpar) Similar to Clonazepam and Adjunct in treatment of refractory OCD Aggression Anxiety Children: initial dose of 2.5 mg to 5 mg with gradual increases to a maximum of 60 mg/day Adolescents: initial dose of 5 to 10 mg with gradual increases to a maximum of 90 mg/day Headaches, nausea, dizziness No cross tolerance with benzodiazepines May take 4 weeks to work Similar to Clonazepam Similar to Clonazepam One to four times per day Page 13 of 20

14 Alpha-Adrenergic Agents Clonidine (nonspecific alpha-2 agonist) (Catapres, Catapres-TTS) ADHD Tic disorder Severe agitation 5-25 µg/kg/d ( mg/d) 1-4 x/d Sedation (very frequent) Hypotension (rare) Dry mouth Confusion (with high dose) Depression Rebound hypertension (when changing dosage or discontinuing drug; therefore, slow tapering of drug advised) Localized irritation with transdermal preparation Bradycardia Cardiovascular disease Family or personal history of mood disorder Abrupt discontinuation of medication Co-administration with beta blockers (without cardiology consultation) Co-administration with Psychostimulants (requires very careful cardiovascular monitoring by physician) Physical exam and routine laboratory, with special attention to cardiovascular system; additional laboratory work including ECG, if Ongoing BP and pulse measurements until dose is stabilized; thereafter every 4 months, or more frequently if there continues to be much side effects Increases drug effect of heterocyclic antidepressants; anti-psychotics, anticholinergic medications and CNS depressants laboratory, other lab, as Guanfacine (selective alpha-2a agonist) (Tenex) ADHD Tic disorders µg/kg/d (1-4 mg/d) Same as Clonidine but less sedation and hypotension Similar to Clonidine Similar to Clonidine 1-3 x/d Page 14 of 20

15 Conventional (Older) Antipsychotics Older Antipsychotics 1. Low potency, i.e., Chlorpromazine, (Thorazine) Thioridazine (Mellaril) 2. High potency: Fluphenazine (Prolixin) Perphenazine (Trilafon) Haloperidol (Haldol) 3. Miscellaneous Thiothixene (Navane) Molindone (Moban) Psychosis Mania Tourette s disorder Secondary use in severe behavior d/o with aggression Secondary use in severe hyperactivity Severe self-abuse mg/kg/d (low potency) mg/kg/d (high potency) mg/kg/d (Navane and Moban) 2-3 x/d Anticholinergic (dry mouth, constipation, blurred vision, orthostatic hypotension, drowsiness - more common with low potency agents) Weight gain (lower risk with molindone) Extrapyramidal reactions (dystonia, rigidity, tremor, akathisia, Parkinsonism - more common with high potency agents) May lower seizure threshold Risk for tardive dyskinesia with long-term administration Withdrawal dyskinesia Neuroleptic malignant syndrome (NMS), extremely rare, necessitating ongoing vigilance for early detection Hyperprolactinemia (more than newer antipsychotics) Liver disease Respiratory distress Breast feeding Avoid using more than one antipsychotic at a time Special Note for Thioridazine: Only for schizophrenia after other antipsychotics are ineffective and the following contraindications: Congenital QT syndrome; QTc interval over 500 msec; cardiac arrhythmias; use of fluvoxamine, propranolol, pindolol, fluoxetine, paroxetine, agents that prolong QTc interval AIMS; ECG for patients with cardiovascular system abnormalities or when high dosages are administered, particularly low potency agents Repeat AIMS every 3 months or more frequently if TD is present Ongoing dyskinesia evaluation Weight at least q 2months Each dose increase measure BP and P Every 6 months: AIMS, weight, LFTs laboratory: CBC + differential, fasting glucose, fasting lipid panel, UA; Other lab, as Pimozide (Orap) Tourette s disorder Start at 0.05 mg/kg/d up to maximum 0.2 mg/kg/d not to exceed 10 mg/day for ages 13 and above No information for those 12 and under Cardiac arrhythmias (ECG: elongated Q-T interval) Seizures Extrapyramidal reactions Drowsiness Tardive dyskinesia Withdrawal dyskinesia NMS Increase in liver enzymes Similar to anti-psychotics plus: Long Q-T intervals (congenital) History of cardiac arrhythmia Other drugs that prolong Q-T interval Similar to anti-psychotics plus liver enzymes repeated every 4 months; ECGs throughout dose adjustment; thereafter, annually Annual physical, and routine laboratory; other laboratory, as 1-4 x/d Page 15 of 20

16 Atypical (Newer) Antipsychotics Newer Atypical antipsychotics 1. Aripiprazole (Abilify) 2. Clozapine (Clozaril) 3. Olanzapine (Zyprexa) 4. Quetiapine (Seroquel) 5. Risperidone (Risperdal) 6. Ziprasidone (Geodon) Psychosis Bipolar Disorder Mania Severe behavior d/o with aggression Secondary use in severe hyperactivity Severe self-abuse mg/d 2. Per Protocol mg/d mg/d mg/d mg/d 1-4 x/d Similar to high potency antipsychotic agents except low incidence of extrapyramidal adverse effects NMS TD Withdrawal dyskinesis Aripiprazole: GI disturbance weight neutral, motor activation Clozapine: Agranulocytosis, seizures, constipation, hypotension, salivation, benign hyperthermia, myocarditis Olanzapine: weight gain, sedation Quetiapine: sedation, weight gain, lenticular opacity Liver disease Respiratory distress Breast feeding Myelosuppression, uncontrolled seizure disorder, (Clozapine only) Avoid using more than one antipsychotic at a time Drugs that reduce plasma level: carbamazepine, phenytoin, phenobarbital, smoking Drugs that increase plasma level: fluoxetine, fluvoxamine, paroxetine, macrolide antibiotic, cimetidine AIMS; ECG for patients with cardiovascular system abnormalities Ongoing dyskinesia evaluation Weight at least q 2 months Each dose increase measure BP and P Every 6 months: AIMS, weight, LFTs, fasting serum glucose, fasting lipid panel laboratory: CBC + differential, fasting glucose, fasting lipid panel, UA; Other lab, as Risperidone: weight gain, sedation Ziprasidone: prolongation of QTc, weight neutral Page 16 of 20

17 Anticholinergic/Antiparkinson and Antihistamine Anticholinergic Benztropine (Cogentin) Trihexyphenidyl (Artane) Procyclidine (Kamadrin) Dopaminergic Antiparkinson Amantadine (Symmetrel) Extrapyramidal reactions (dystonia, rigidity, tremor akathisia) / 6 mg/day x/day / 6 mg/day x/day / 8 mg/day x/day / 3-9y/o 150 mg/day 9-17y/o 200 mg/day 2-3 x/day Dry mouth, constipation, blurred vision Decrease in neuroleptic serum concentration Worsening of pre-existing psychotic symptoms Aggravation of asthma Confusion, disorientation, hallucinations, cognitive dulling, impaired memory Headache, tachycardia, pupillary dilation, flushed-dry-hot skin Delirium, coma (not common, but can occur with high doses) Abuse potential (may produce a buzz ) Less than three years old Exposure to heat, severe physical stress Closed angle glaucoma (check intra-ocular pressure) Obstructive bowel disease, megacolon Co-administration of MAO inhibitors Co-administration of other parasymapatholytic agents, (TCA s, low potency anti psychotics), nursing Asthma Coordinate with work-up in regard to anti-psychotics Antihistamine Sedative/Hypnotic / Similar to Cogentin Similar to Cogentin plus: Diphenhydramine (Benadryl) Hydroxyzine (Atarax, Vistaril) > 10y/o 300 mg/day < 10y/o 150 mg/day < 6y/o 50 mg/day 3-4 x/day, nursing Annual physical, and routine laboratory; other laboratory, as Page 17 of 20

18 Beta-Adrenergic Blocker Propranolol (Inderal) Severe agitation Aggression Akathisia Anxiety PTSD mg/kg/d ( mg/d) 2-4 x/d Similar to Clonidine Higher risk for bradycardia and hypotension (dose dependent) and rebound hypertension Bronchospasm Rebound hypertension on abrupt withdrawal Bronchospastic disease Asthma, Diabetes Hyperthyroidism Co-administration with MAO inhibitors Cardiovascular disease Similar to Clonidine Opiate Blocker Naltrexone (Trexan) Self-injurious behavior in MR and autism mg/kg/d Sedation Liver dysfunction, concurrent opiate use Annual physical, and routine laboratory 1 x/d Page 18 of 20

19 Hypnotic Zolpidem (Ambien) Insomnia (short term treatment) 5-10 mg/d 1 x/d Rarely may cause paradoxical agitation CNS Depression: Fatigue, drowsiness, ataxia, confusion respiratory depression Incoordination, slurred speech, diplopia, tremor Dyscontrol, disinhibition, excitation, increased anxiety, increased aggression Rage reaction, hallucinations, insomnia, nightmares Rebound and withdrawal reactions / or risk of pregnancy Co-morbid substance abuse or dependency Effect potentiated by: phenothiazines, opiates, barbiturates, MAOI s, TCA s, cimedtidine Potentiates effects of: hypnotics, sedatives, alcohol Half-life extended by: liver disease Annual physical, and routine laboratory Page 19 of 20

20 References Pediatric Dosage Handbook. Taketomo, C.K., Hodding, J.H., Kraus, D.M., Hudson, OH: Lexi-Comp. Journal of Child and Adolescent Psychopharmacology, (periodical) Larchmont, NY: Mary Ann Liebert, Inc. Psychiatry Drug Alerts (periodical). Morristown, NJ: M.J. Powers & Company. Journal of the American Academy of Child and Adolescent Psychiatry, (periodical). Baltimore, MD, William & Wilkins. American Academy of Child and Adolescent Psychiatry, Practice Parameters (periodical) American Journal of Psychiatry: Journal of the American Psychiatric Association (periodical). Child and Adolescent Psychiatric Clinics of North America. W.B. Saunders; Pennsylvania Psychiatric Clinics of North America. W.B. Saunders; Pennsylvania Annual of Drug Therapy. W.B. Saunders; Pennsylvania Page 20 of 20