4/2/13 COMMON CLASSES OF MEDICATIONS. Child & Adolescent Behavioral Medicine & Medication Therapies. Behavioral Medicine & Medication Therapies

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1 Child & Adolescent Behavioral Medicine & Medication Therapies Brian J Cowles, PharmD Associate Professor of Pharmacy Practice Albany College of Pharmacy & Health Sciences; Vermont Campus Behavioral Medicine & Medication Therapies List at least three difficulties in the diagnoses and treatment of behavioral disorders Match common problematic behaviors to common associated medication treatments Describe how potential medication side effects can be distinguished from new changes in behaviors COMMON CLASSES OF MEDICATIONS 1

2 Selective Serotonin Reuptake Inhibitors (SSRIs) Fluoxetine (PROZAC ); Fluvoxamine (LUVOX ); Citalopram (CELEXA ); Escitalopram (LEXAPRO ) Antipsychotics or Neuroleptics Risperidone (RISPERAL ); Aripiprazole (ABILIFY ); Olanzapine (ZYPREXA ); Quetiapine (SEROQUEL ) Haloperidol (HALDOL ); Clozapine (CLOZARIL ) Stimulants & Non-Stimulants Methylphenidate (RITALIN ; METADATE ; CONCERTA; DAYTRANA ) Amphetamine derivatives (ADDERALL ; Lisdexamfetamine, VYVANSE ; DEXEDRINE ) Atomoxetine (STRATTERA ) Alpha-Agonists Clonidine (CATAPRES ); Guanfacine (TENEX ) Tricyclic Antidepressants (TCAs) Imipramine (TOFRANIL ); Amitriptyline (ELAVIL ); Clomipramine (ANAFRANIL ) Anticonvulsants Carbamazepine (TEGRETOL ; CARBATROL ); Valproate (DEPAKOTE ); Gabapentin (NEURONTIN ) Sedatives & Hypnotics Benzodiazepines: Diazepam (VALIUM ); Alprazolam (XANAX ); Clonazepam (KLONOPIN ) Non-benzodiazepines: Zolpidem (AMBIEN ); Zaleplon (SONATA ); Ramelteon (ROZEREM ) Miscellaneous Lithium; Mirtazapine; Buspirone; Trazadone DEVELOPMENTAL AND BEHAVIORAL MEDICINE 2

3 Behavior The way in which one acts or conducts oneself, especially towards others (New Oxford American Dictionary, 2005) Any response emitted by or elicited from an organism; any mental or motor act or activity; Parts of a total response pattern (Stedman s Medical Dictionary, 28 th ed) Developmental Disorders Behavioral Disorders Psychosocial Issues Cerebral palsy Intellectual disability Spina bifida Au9sm Discipline Sleep Aggression Socio- politcal influences Cultural influences Religious influences Family structure Developmental Individual s relationship with oneself & one s environment Psychosocial Behavioral 3

4 Developmental & Behavioral Diagnosis Continuous Categorical Blood pressure Hypo- vs. hypertension Body temperature Hypothermic vs. febrile Height Dwarfism vs. gigantism Hyperactivity??? Aggression??? Inattention??? Developmental & Behavioral Diagnosis Outliers Majority Outliers BEHAVIOR-TARGETED MEDICATION THERAPY 4

5 Why Behavior-Targeted Treatment? DSM forces us to think in terms of specific, coded diagnoses Medications affect change on behaviors, not diagnoses DSM Diagnostic & Statistical Manual COMMON BEHAVIOR- TARGETED THERAPIES Problematic Behavior Inattention & hyperactivity Commonly Associated Diagnoses ADHD; Autism; Learning Disorder; Language Disorder Common Medication Therapies Stimulants; Non-stimulants; Alpha-agonists 5

6 Problematic Behavior Aggression; Self-injury; Irritability Commonly Associated Diagnoses Intellectual Disability; Autism; Conduct Disorder; Oppostitional Defiant Disorder; Stereotypic Disorder Common Medication Therapies Antipsychotics; Anticonvulsants; Lithium Problematic Behavior Stereotypies & Compulsive Behaviors Commonly Associated Diagnoses Autism; Stereotypic Disorder Common Medication Therapies SSRIs Problematic Behavior Anxiety Commonly Associated Diagnoses Autism; Selective Mutism; Separation Anxiety; Elimination Disorders Common Medication Therapies SSRIs; TCAs; Buspirone 6

7 Problematic Behavior Tics Commonly Associated Diagnoses Tic Disorders; ADHD Common Medication Therapies Alpha-agonists; Antipsychotics Problematic Behavior Sleep Difficulties Commonly Associated Diagnoses Autism; Intellectual Disability; ADHD Common Medication Therapies Trazadone; Mirtazapine; TCAs; Benzodiazepines; Non-Benzodiazepine Hypnotics EVALUATION OF POTENTIAL SIDE EFFECTS 7

8 Evaluating Side Effects Medication side effect vs. emerging problematic behavior? Onset? Recent dosing changes? Time relationship to dosing? Common known side effect? STIMULANTS Irritability; headache; appetite suppression; sleep disturbances Concerns: growth; cardiac risk; tics NON-STIMULANTS (atomoxetine; Strattera ) Gastrointestinal complaints Concerns: cardiac risk; liver injury 8

9 ANTIPSYCHOTICS Weight-gain; glucose control; lipid control Cardiac conduction issues Movement disorders; poor muscular coordination SELECTIVE SERONIN REUPTAKE INHIBITORS Behavioral changes; activation; hypomania Headache; GI complaints; sleep disturbances Concerns: Suicidal thinking ALPHA-AGONISTS Drowsiness; decreased blood pressure 9

10 TRICYCLIC ANTIDEPRESSANTS Flushing; urine retention; sweating; dry mouth; confusion/disorientation Cardiac conduction (EKG) changes; increased heart rate ANTICONVULSANTS Valproate: headache; sleep disturbances; GI complaints; liver dysfunction Carbamazepine: confusion; loss of muscle control; fatigue; photosensitivity; severe rashes Gabapentin: somnolence; loss of muscle control; fatigue SEDATIVES & HYPNOTICS Benzodiazepines: loss of muscle control; confusion; drowsiness Non-benzodiazepine hypnotics: dizzyness; headache; vivid dreams/nightmares 10

11 MISCELLANEOUS Lithium: cardiac conduction problems; endocrine problems; dry mouth; tremor Trazodone: dizziness; headache; dry mouth Mirtazipine: somnolence; constipation; dry mouth CLINICAL APPLICATION OF MEDICATION THERAPY Medication Dosing Diagnosis medication Behavior medication Behavior adversely affecting individual may indicate medication therapy Start low, go slow Defined dose-side effect relationship Increased sensitivity to side effects (developmentally disabled) 11

12 Medication Dosing DOSING RANGES & TITRATION Initial dosing often not effective, but safe Dosing increased to desired effect or side effects Inter-individual differences: pharmacokinetics & pharmacogenetics Variability in effective doses between various populations Medication Discontinuation Realistic outcomes & a tight leash When is enough enough? Periodic discontinuation Assessment of underlying behavior Tapering and discontinuation May be complicated by placebo effect Behavioral Medicine & Medication Therapies RESOURCES FOR FURTHER INFORMATION Medline Plus emedicine Pediatric Developmental & Behavioral resources Am Acad of Child & Adolescent Psychiatry 12

13 Behavioral Medicine & Medication Therapies List at least three difficulties in the diagnoses and treatment of behavioral disorders Match common problematic behaviors to common associated medication treatments Describe how potential medication side effects can be distinguished from new changes in behaviors 13

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