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  • 34 PsychoPharmacology Bulletin: Vol. 48 No. 2

    Educational REviEw

    Dosing and Monitoring: Children and Adolescents

    By Glenn S. Hirsch

    IntroductIon

    American culture places a great value on our children. In accordance with this, parents seek out the best health care, wanting to ensure the well-being of their children. Despite this, physicians have been forced to treat children with medica-tions lacking FDA indications for pediatric use. Off-label use to treat childhood disorders has been the rule rather than the exception, with clinicians relying on limited literature or clinical lore to make important medical decisions.

    The treatment of psychiatric disorders in children has been no exception. Medications approved for adults gradually make their way into the armamen-tarium of child and adolescent psychiatrists, often without adequate dosing guidelines. The past two decades have seen a dramatic increase in the number of studies looking specifically at pediatric psychopharmacology, but there have been difficulties in obtaining funding for such work. Pediatric studies have also been hampered by the lack of understanding of the biologic nature of many psychiatric disorders.

    Numerous factors have worked together to begin changing these problems. In1994, the FDA enacted the Pediatric Labeling Regulation, which encouraged pharmaceutical firms to submit applications for a change in labeling for pediatric indications if a review of the literature showed that enough data existed to war-rant a pediatric indication.

    As part of the Food and Drug Administration Modernization Act of 1997 (enacted in 1998), pediatric exclusivity could be extended by 6 months for medi-cations whose manufacturers submitted pediatric studies in compliance with the acts regulations. In addition, the Pediatric Rule, effective April 1999, required certain manufacturersnamely those of products that would either be used in a substantial number of pediatric patients or provide children a meaningful

    Journal name: Psychopharmacology BulletinVolume no: 48Issue no: 2Year: 2018Article designation: Educational ReviewRunning heading title: Dosing and Monitoring: Children and Adolescents

    Dr. Hirsch is Vice Chair for Clinical Affairs, Department of Child and Adolescent Psychiatry and Child Study Center of the Hassenfeld Childrens Hospital at NYU Langone and Associate Professor of Child and Adolescent Psychiatry, Psychiatry, and Pediatrics.To whom correspondence should be addressed: James M. La Rossa Jr., Publisher, 2205 Rockefeller Lane, Bldg. B, Redondo Beach, CA 90278. Phone: 310.374.1300; Fax: 424.398.0067; E-mail: editorial@medworksmedia.com

    Psychopharmacol Bull. 2018;48(2):3492.

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    PsychoPharmacology Bulletin: Vol. 48 No. 2

    therapeutic benefit over existing treatmentsto conduct studies that would be adequate to provide labeling for pediatric indications.

    In addition, the NIMH funded the Research Units in Pediatric Psychopharmacology (RUPP) network. RUPP is composed of research units in academic centers across the country devoted to conduct-ing studies to test the efficacy and safety of medications commonly used by practitioners to treat children and adolescents but not yet adequately tested.

    The number of pediatric studies and submissions to the FDA has subsequently increased dramatically. Clearly this has allowed new fund-ing sources to assist in the development of pharmacological trials. It has also assisted in allaying the resistance that is often seen toward treatment studies in young children. As public awareness of psychiatric disorders has grown, resistance toward research has begun to diminish.

    As our knowledge of pediatric psychopharmacology increa ses, it becomes increasingly difficult to keep track of the available options for treatment. While it is beyond the scope of this book to cover all the factors that make the treatment of children different from that of adults, we have attempted to compile a practical guide for those in the trenches. Medications commonly used in children and adolescents, as well as general dosing guidelines, have been provided.

    In addition to the dosing and monitoring tables that follow, there are a number of overarching principles to keep in mind in treating this vul-nerable population. The latest recommendations for use of psychotro-pic medication from the American Academy of Child and Adolescent Psychiatry (AACAP) greatly expanded guidelines for clinicians. These guidelines for dosing and monitoring in children and adolescents will follow the AACAPs lead.

    Psychiatrists, pediatric neurologists, and pediatricians whose patients may present on a medication they are less familiar with will hopefully find this guide helpful.

    We hope the following will enhance the ease with which you practice, and we look forward to your suggestions for future updates.

    Editorial Director, James M. La Rossa Jr.,contributed to the 2018 update of this work

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    PsychoPharmacology Bulletin: Vol. 48 No. 2

    TABLE 1

    Psychotropic Agents (by Generic)

    GENERIC BRAND NAMEDOSAGE RANGE*

    (mg/day)Alprazolam Xanax

    Xanax XR14

    Amantadine Symmetrel 100300Amisulpride Soilan 4001200Amitriptyline Elavil 50300Amoxapine Asendin 200600Amphetamine-D Dexedrine 540Amphetamine/

    dextroamphetamineAdderallAdderall Xr

    540

    Aripiprazole AbilifyAbilify Maintena (Injectable)

    230

    Armodafinil Nuvigil 150250Asenapine Saphris 1020Atomexetine Strattera 40100bBenztropin Cogentin 0.56Biperiden Akineton 224Blonanserin Lonasen 816Brexpiprazole Rexulti 24Buprenorphine Suboxon (w/Naloxone)

    Probuphine Implant832

    Bupropion WellbutrinWellbutrin SRWellbutrin XL

    200450

    Buspirone BuSpar 2060Carbamazepine Tegretol

    Tefgretol XRCarbatrol

    4001,600

    Cariprazine Vraylar 1.56Chlordiazepoxide Librium

    LimibitrolLibrax

    1540

    Chlorpromazine Thorazine 200800Citalopram Celexa 2040Clomipramine Anafranil 100250Clonazepam Klonopin 0.54Clonidine Catapres

    KapvayIntunivDuraclon (Injectable)

    0.10.4

    Clorazepate AzeneTranxene

    1560

    Clozapine ClozarilLeponexVersacloz (oral suspension)Fazaclo ODT (oral tablets)

    25700

    (Continued)

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    PsychoPharmacology Bulletin: Vol. 48 No. 2

    GENERIC BRAND NAMEDOSAGE RANGE*

    (mg/day)Desipramine Norpramin 100300Desvenlafaxine Prestiq 50100Dextromethorphan Nuedexta 1020Diazepam Valium 440Diphenhydramine Benadryl

    Sominex injection:50

    1050D-methamphetamine Desoxyn 2025Disulfiram Antabuse 250500Donepezil Aricept 510Doxepin Sinequan

    Silenor75150

    Droperidol Inapsine 2.515Duloxetine Cymbalta 60120Escitalopram Lexapro 1040Estazolam ProSom 14Eszopiclone Lunesta 13Ethosuximide Zarontin 1540Flibanserin Addyi 100Fluoxetine Prozac

    Sarafem2080

    Flupenthixol Depixol 36Fluphenazine Prolixin 140Fluphenazine decanoate Prolixin Decanaote 120Flurazepam Dalmane 1530Fluvoxamine Luvox

    Luvox CR100300

    Gabapentin NeurontinGralise (XR)Horizant (XR)

    9003,600

    Galantamine ReminylRazadyne

    1624

    Haloperidol Haldol 140Haloperidol decanoate Haldol Decanaote 50100 mg/mLHydroxyzine Atarax

    MaraxVistaril

    50100

    Iloperidone Fanapt 1232Imipramine Tofranil 150300Imipramine Pamoate Tofranil-PM 150300Intuniv XR

    (Guanfacine XR )IntunivTenex

    14

    Isocarboxazid Marplan 4060Lamotrigine Lamictal

    Lamictal ODTLamictal XR

    100400

    TABLE 1 (Continued)

    Psychotropic Agents (by Generic)

    (Continued)

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    PsychoPharmacology Bulletin: Vol. 48 No. 2

    GENERIC BRAND NAMEDOSAGE RANGE*

    (mg/day)Levetiracetam Keppra

    Keppra XR1,0003,000

    Levomilnacipran Fetzima 40120Lisdexamfetamine Vyvanse 3070Lithium carbonate Eskalith

    Eskalith CRLithobid (slow release)

    6001,800

    Lofepramine DeprimylGamanil

    140210

    Lorazepam Ativan 16Loxapine Loxitane, Adasuve 20250Lurasidone Latuda 2080Maprotiline Ludiomil 75225Memantine Namenda

    Namenda XR528

    Mesoridazine SerentilLidanil

    100400

    Methylphenidate ConcertaRitalin, Ritalin-SRRitalin LA, Metadate ER Metadate CD Methylin (chewable)Methylin ERDaytrana (Trans. Patch)Quillichew ERContempla XR-ODTFocalinFocalin XR

    18721060

    2060

    5301040

    Mianserin Lerivon 3090Milnacipran Savella

    IxelToledomin

    100200

    Mirtazapine Remeron 1545Moclobemide Aurorix

    ArimaManerix

    300600

    Modafinil ProvigilAlertecModiodal

    50800

    Molindone Moban 40225Naltrexone Revia

    Vivitrol (injection)50150

    380 mg/4 wksNaltrexone-Buproprion Contrave 16/180 bidNefazodone Serzone 300600Nortriptyline Pamelor 50300

    TABLE 1 (Continued)

    Psychotropic Agents (by Generic)

    (Continued)

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    PsychoPharmacology Bulletin: Vol. 48 No. 2

    GENERIC BRAND NAME

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