the role of polypharmacy in children with developmental disability: art or science natalie silove...
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The role of polypharmacy in children with developmental
disability: Art or science
Natalie SiloveCHW
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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 +++
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• 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
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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
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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/behavioural/parenting/social support/referrals etc
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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
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• 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
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• 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
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• 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.
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• 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!
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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
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PolypharmacyLiterature 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
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13
SRI
NRI
DRI5HT2C
m-ACh
NOS
CYP 2D6
1A2
CYP 3A4
SSRI
6-40 Stahl S M, Essential Psychopharmacology (2000)
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Drug cocktails• Pharmacological rich
• Multireceptor focus
• Individualised medication
• Potential for drug interactions both pharmacodynamic and pharmacokinetic
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mechanism
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When serotonin receptor blockade added
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When noradrenaline blockade is added
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Summary of receptors and adverse effects
drug receptor Common adverse and positive effect
amitriptyline 1hypotension
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
H1Weight gain, drowsiness
clonidine 2 3Drowsiness, 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
naltrexone Mu Decrease pleasure response
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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
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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
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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
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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