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London EB, Zimmerman-Bier BL, Yoo JH, Gaffney JW. High-Dose Propranolol for Severe and Chronic Aggression in Autism Spectrum Disorder: A Pilot, Double-Blind, Placebo-Controlled, Randomized Crossover Study. J Clin Psychopharmacol 2024; 44:462-467. [PMID: 39174017 DOI: 10.1097/jcp.0000000000001895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/24/2024]
Abstract
BACKGROUND Despite the use of behavioral interventions and psychotropic medications, many individuals with autism spectrum disorder (ASD) who engage in severe aggression remain refractory to conventional treatment. Propranolol, a beta-blocker, has accumulated much anecdotal evidence as a promising option. However, well-designed studies are rare, and the apprehension about cardiovascular side effects from large doses continues to exist. PURPOSE The aims of this study were (1) to demonstrate the feasibility of treating aggression with high-dose propranolol using telehealth study visits and (2) to document cardiac safety. METHODS This study utilized a randomized, double-blind, placebo-controlled, crossover design. Dosing was titrated up in a flexible but stepwise fashion until therapeutic response was obtained or up to 200 mg tid. Following washout, those who were assigned propranolol were crossed over to placebo and vice versa. Six participants between the ages 12-19 participated. The primary outcome measures were the final Clinical Global Impression Improvement Scale (CGI-I) and the Aberrant Behavior Checklist-Community Irritability (ABC-C/I) scores at 200 mg tid. RESULTS The CGI-I indicated a 50% reduction in symptoms in the propranolol phase, while the ABC-I indicated a 37% reduction in comparison to placebo. The effect sizes ( r ) for the CGI-I and the ABC-C/I were large, -0.74 and -0.64, respectively. The average blood pressure was 122/68 during the placebo phase and 109/72 during the propranolol phase. All Holter monitor exams were unremarkable. CONCLUSION These results suggest that propranolol is an effective option in decreasing aggression in individuals with ASD. As this was a small study, a larger clinical trial is needed.
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Affiliation(s)
- Eric B London
- From the New York State Institute for Basic Research, Department of Psychology, Staten Island, NY
| | - Barbie L Zimmerman-Bier
- Rutgers University Robert Wood Johnson Medical School and the Children's Health Institute, New Brunswick, NJ
| | - J Helen Yoo
- From the New York State Institute for Basic Research, Department of Psychology, Staten Island, NY
| | - Joseph W Gaffney
- Rutgers University Robert Wood Johnson Medical School and the Children's Health Institute, New Brunswick, NJ
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Korb L, Tromans S, Perera B, Khan N, Burrows L, Laugharne R, Hassiotis A, Allgar V, Efron D, Maidment I, Shankar R. The potential for medicinal cannabis to help manage challenging behaviour in people with intellectual disability: A perspective review. J Psychopharmacol 2023; 37:1201-1208. [PMID: 37937428 PMCID: PMC10714688 DOI: 10.1177/02698811231209192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2023]
Abstract
BACKGROUND Around 2% of the population have intellectual disabilities. Over one-third people with intellectual disabilities (PwID) present with 'challenging behaviour', which nosologically and diagnostically is an abstract concept. Challenging behaviour is influenced by a range of bio-psycho-social factors in a population, which is unable to suitably comprehend and/or communicate concerns. This predisposes to poor health and social outcomes. There is no evidence-based treatments for managing challenging behaviour. Cannabidiol (CBD) and tetrahydrocannabinol (THC) are being trialled for a range of disorders, which are over-represented in PwID and provoke challenging behaviours, such as severe epilepsy, spasticity, post-traumatic stress disorder, social phobia, pain, etc. METHODS This perspective review explores the different conditions, which benefit from medicinal CBD/THC preparations, by analysing recent literature from neurobiological, pre-clinical and clinical studies related to the topic. The evidence is synthesised to build an argument of the therapeutic benefits and challenges of medicinal cannabis to manage severe challenging behaviour in PwID. RESULTS There is developing evidence of medicinal CBD/THC improving psychiatric and behavioural presentations in general. In particular, there is emergent proof in certain key areas of influence of medicinal CBD/THC positively supporting challenging behaviour, for example in children with neurodevelopmental disorders. However, there are significant challenges in employing such treatments in vulnerable populations such as PwID. CONCLUSION Further clinical research for the considered use of medicinal CBD/THC for challenging behaviour management in PwID is needed. Strong co-production with experts with lived experience is needed for further testing to be done in this exciting new area.
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Affiliation(s)
- Laura Korb
- Haringey Learning Disability Partnership, Barnet Enfield and Haringey Mental Health NHS Trust, London, UK
| | - Samuel Tromans
- Department of Population Health Sciences, University of Leicester, Leicester, UK
- Adult Learning Disability Service, Leicestershire Partnership NHS Trust, Leicester, UK
| | - Bhathika Perera
- North East London NHS Foundation Trust, London, UK
- Division of Psychiatry, University College London, London, UK
| | - Nagina Khan
- Centre for Addiction and Mental Health, Toronto, Canada
| | | | - Richard Laugharne
- Cornwall Intellectual Disability Equitable Research (CIDER), University of Plymouth Peninsula School of Medicine, Truro, UK
| | | | - Victoria Allgar
- Peninsula Clinical Trials Unit, Faculty of Health, University of Plymouth, Truro, UK
| | - Daryl Efron
- Royal Children’s Hospital, Melbourne, Australia
- Murdoch Children’s Research Institute, Melbourne, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, Australia
| | - Ian Maidment
- College of Life and Health Sciences, Aston School of Pharmacy, Aston University, Birmingham, UK
| | - Rohit Shankar
- Cornwall Intellectual Disability Equitable Research (CIDER), University of Plymouth Peninsula School of Medicine, Truro, UK
- Peninsula Clinical Trials Unit, Faculty of Health, University of Plymouth, Truro, UK
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Molero Y, Kaddoura S, Kuja-Halkola R, Larsson H, Lichtenstein P, D’Onofrio BM, Fazel S. Associations between β-blockers and psychiatric and behavioural outcomes: A population-based cohort study of 1.4 million individuals in Sweden. PLoS Med 2023; 20:e1004164. [PMID: 36719888 PMCID: PMC9888684 DOI: 10.1371/journal.pmed.1004164] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 12/28/2022] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND β-blockers are widely used for treating cardiac conditions and are suggested for the treatment of anxiety and aggression, although research is conflicting and limited by methodological problems. In addition, β-blockers have been associated with precipitating other psychiatric disorders and suicidal behaviour, but findings are mixed. We aimed to examine associations between β-blockers and psychiatric and behavioural outcomes in a large population-based cohort in Sweden. METHODS AND FINDINGS We conducted a population-based longitudinal cohort study using Swedish nationwide high-quality healthcare, mortality, and crime registers. We included 1,400,766 individuals aged 15 years or older who had collected β-blocker prescriptions and followed them for 8 years between 2006 and 2013. We linked register data on dispensed β-blocker prescriptions with main outcomes, hospitalisations for psychiatric disorders (not including self-injurious behaviour or suicide attempts), suicidal behaviour (including deaths from suicide), and charges of violent crime. We applied within-individual Cox proportional hazards regression to compare periods on treatment with periods off treatment within each individual in order to reduce possible confounding by indication, as this model inherently adjusts for all stable confounders (e.g., genetics and health history). We also adjusted for age as a time-varying covariate. In further analyses, we adjusted by stated indications, prevalent users, cardiac severity, psychiatric and crime history, individual β-blockers, β-blocker selectivity and solubility, and use of other medications. In the cohort, 86.8% (n = 1,215,247) were 50 years and over, and 52.2% (n = 731,322) were women. During the study period, 6.9% (n = 96,801) of the β-blocker users were hospitalised for a psychiatric disorder, 0.7% (n = 9,960) presented with suicidal behaviour, and 0.7% (n = 9,405) were charged with a violent crime. There was heterogeneity in the direction of results; within-individual analyses showed that periods of β-blocker treatment were associated with reduced hazards of psychiatric hospitalisations (hazard ratio [HR]: 0.92, 95% confidence interval [CI]: 0.91 to 0.93, p < 0.001), charges of violent crime (HR: 0.87, 95% CI: 0.81 to 0.93, p < 0.001), and increased hazards of suicidal behaviour (HR: 1.08, 95% CI: 1.02 to 1.15, p = 0.012). After stratifying by diagnosis, reduced associations with psychiatric hospitalisations during β-blocker treatment were mainly driven by lower hospitalisation rates due to depressive (HR: 0.92, 95% CI: 0.89 to 0.96, p < 0.001) and psychotic disorders (HR: 0.89, 95% CI: 0.85 to 0.93, p < 0.001). Reduced associations with violent charges remained in most sensitivity analyses, while associations with psychiatric hospitalisations and suicidal behaviour were inconsistent. Limitations include that the within-individual model does not account for confounders that could change during treatment, unless measured and adjusted for in the model. CONCLUSIONS In this population-wide study, we found no consistent links between β-blockers and psychiatric outcomes. However, β-blockers were associated with reductions in violence, which remained in sensitivity analyses. The use of β-blockers to manage aggression and violence could be investigated further.
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Affiliation(s)
- Yasmina Molero
- Department of Clinical Neuroscience, Centre for Psychiatry Research, Karolinska Institutet, Stockholm, Sweden
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Sam Kaddoura
- School of Medicine, Imperial College, London, United Kingdom
- Chelsea and Westminster Hospital, London, United Kingdom
- Royal Brompton Hospital, London, United Kingdom
| | - Ralf Kuja-Halkola
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Henrik Larsson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Paul Lichtenstein
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Brian M. D’Onofrio
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Department of Psychological and Brain Sciences, Indiana University, Bloomington, Indiana, United States of America
| | - Seena Fazel
- Department of Psychiatry, University of Oxford, Oxford, United Kingdom
- Oxford Health NHS Foundation Trust, Oxford, United Kingdom
- * E-mail:
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Pharmacotherapy of Disruptive Behaviors in Children with Intellectual Disabilities. Paediatr Drugs 2022; 24:465-482. [PMID: 35781194 DOI: 10.1007/s40272-022-00517-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/24/2022] [Indexed: 10/17/2022]
Abstract
Disruptive behaviors are a class of predominantly externalizing behaviors that include physical aggression, property destruction, temper outbursts, verbal aggression, and some forms of self-injurious behaviors. Externalizing behaviors are also major components of disruptive, impulse-control and conduct disorders, disruptive mood dysregulation disorder, trauma-related and stressor-related disorders, intermittent explosive disorder, personality disorders, and other neuropsychiatric and neurodevelopmental disorders. Disruptive behaviors and associated disorders are among the most frequent reasons for child behavioral health referrals and are the most common reason for referrals among children with intellectual disabilities. The focus of this paper is on the adjunctive role of integrated psychopharmacological treatment in the management of children with disruptive behaviors and co-occurring intellectual disabilities. The decision-making process for adding pharmacotherapy to a comprehensive treatment plan incorporates not only a working knowledge of basic behavioral neurobiology of disruptive behaviors but also an understanding of the strengths and weaknesses of various pharmacotherapies. Importantly, there is little evidence to support the use of psychopharmacologic agents in managing difficult behaviors in children with intellectual disabilities, but with that said, risperidone has the strongest evidence base for its use.
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Totsika V, Liew A, Absoud M, Adnams C, Emerson E. Mental health problems in children with intellectual disability. THE LANCET. CHILD & ADOLESCENT HEALTH 2022; 6:432-444. [PMID: 35421380 DOI: 10.1016/s2352-4642(22)00067-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 02/21/2022] [Accepted: 02/21/2022] [Indexed: 12/16/2022]
Abstract
Intellectual disability ranks in the top ten causes of disease burden globally and is the top cause in children younger than 5 years. 2-3% of children have an intellectual disability, and about 15% of children present with differences consistent with an intellectual disability (ie, global developmental delay and borderline intellectual functioning). In this Review, we discuss the prevalence of mental health problems, interventions to address these, and issues of access to treatment and services. Where possible, we take a global perspective, given most children with intellectual disability live in low-income and middle-income countries. Approximately 40% of children with intellectual disability present with a diagnosable mental disorder, a rate that is at least double that in children without intellectual disability. Most risk factors for poor mental health and barriers to accessing support are not unique to people with intellectual disability. With proportionate universalism as the guiding principle for reducing poor mental health at scale, we discuss four directions for addressing the mental health inequity in intellectual disability.
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Affiliation(s)
- Vasiliki Totsika
- Division of Psychiatry, University College London, London, UK; Department of Psychiatry, Centre for Developmental Psychiatry and Psychology, Monash University, Melbourne, VIC, Australia; Centre for Educational Development Appraisal and Research (CEDAR), University of Warwick, Coventry, UK; Tavistock & Portman NHS Foundation Trust, London, UK.
| | - Ashley Liew
- Centre for Educational Development Appraisal and Research (CEDAR), University of Warwick, Coventry, UK; National & Specialist CAMHS, South London and Maudsley NHS Foundation Trust, London, UK; Department of Children's Neurosciences, Evelina London Children's Hospital, Guys and St Thomas' NHS Foundation Trust, London, UK; Institute for Mental Health, University of Birmingham, Birmingham, UK
| | - Michael Absoud
- Department of Children's Neurosciences, Evelina London Children's Hospital, Guys and St Thomas' NHS Foundation Trust, London, UK; Department of Women and Children's Health, Faculty of Life Sciences and Medicine, School of Life Course Sciences, King's College London, London, UK
| | - Colleen Adnams
- Division of Intellectual Disability, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - Eric Emerson
- Centre for Disability Research, Faculty of Health & Medicine, Lancaster University, Lancaster, UK; Centre for Disability Research & Policy, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia; College of Nursing and Health Sciences, Flinders University, Adelaide, SA, Australia
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Popow C, Ohmann S, Plener P. Practitioner's review: medication for children and adolescents with autism spectrum disorder (ASD) and comorbid conditions. NEUROPSYCHIATRIE : KLINIK, DIAGNOSTIK, THERAPIE UND REHABILITATION : ORGAN DER GESELLSCHAFT OSTERREICHISCHER NERVENARZTE UND PSYCHIATER 2021; 35:113-134. [PMID: 34160787 PMCID: PMC8429404 DOI: 10.1007/s40211-021-00395-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 05/15/2021] [Indexed: 11/14/2022]
Abstract
Alleviating the multiple problems of children with autism spectrum disorder (ASD) and its comorbid conditions presents major challenges for the affected children, parents, and therapists. Because of a complex psychopathology, structured therapy and parent training are not always sufficient, especially for those patients with intellectual disability (ID) and multiple comorbidities. Moreover, structured therapy is not available for a large number of patients, and pharmacological support is often needed, especially in those children with additional attention deficit/hyperactivity and oppositional defiant, conduct, and sleep disorders.
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Affiliation(s)
- Christian Popow
- Dept. Child and Adolescent Psychiatry, Medical University of Vienna, Waehringer Guertel 18–20, 1090 Vienna, Austria
| | - Susanne Ohmann
- Dept. Child and Adolescent Psychiatry, Medical University of Vienna, Waehringer Guertel 18–20, 1090 Vienna, Austria
| | - Paul Plener
- Dept. Child and Adolescent Psychiatry, Medical University of Vienna, Waehringer Guertel 18–20, 1090 Vienna, Austria
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London EB, Yoo JH. From Research to Practice: Toward the Examination of Combined Interventions for Autism Spectrum Disorders. Brain Sci 2021; 11:1073. [PMID: 34439691 PMCID: PMC8391105 DOI: 10.3390/brainsci11081073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 07/25/2021] [Accepted: 08/06/2021] [Indexed: 12/04/2022] Open
Abstract
The use of biological (i.e., medications) in conjunction with applied behavior analysis is relatively common among people with ASD, yet research examining its benefit is scarce. This paper provides a brief overview of the existing literature on the combined interventions, including promising developments, and examines the existing barriers that hinder research in this area, including the heavy reliance on RCTs. Recommendations for possible solutions, including the creation of health homes, are provided in order to move toward a more integrated approach.
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Affiliation(s)
- Eric Bart London
- Department of Psychology, New York State Institute for Basic Research in Developmental Disabilities, 1050 Forest Hill Road Staten Island, New York, NY 10314, USA;
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The Use of β-Adrenergic Receptor Antagonists in Psychiatry: A Review. J Acad Consult Liaison Psychiatry 2021; 62:404-412. [PMID: 34210401 DOI: 10.1016/j.jaclp.2020.12.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 12/19/2020] [Accepted: 12/20/2020] [Indexed: 01/05/2023]
Abstract
BACKGROUND β-Blockers (BBs) are a widely used class of medications with a number of medical indications. Their ability to suppress the adrenergic response has made them a target of investigation for treating a variety of psychiatric symptoms. OBJECTIVE The aim of this review is to identify evidence regarding the use of BBs for various psychiatric disorders including anxiety disorders, mood disorders, psychosis, and posttraumatic stress disorder. We also review the evidence for use for aggression and agitation and for extrapyramidal side effects of psychiatric medications. METHODS A search of PubMed and Google Scholar was conducted with search terms relevant to the use of BBs for psychiatric conditions. Studies were selected based on relevance to the review objective, focusing on systematic reviews and meta-analyses. Case reports were included and are clearly identified when referenced in this review. RESULTS A total of 44 publications were included that examined the use of BBs as treatment for the following psychiatric symptoms and conditions: anxiety disorders, depression and mood disorders, acute stress disorder and postraumatic stress disorder, psychotic disorders and extrapyramidal symptoms, as well as aggression and agitation. Additionally, adverse effects and drug-drug interactions were reviewed. CONCLUSION Well-characterized psychiatric uses of BBs include treating symptoms of performance anxiety and akathisia. Some positive evidence exists for BB therapy in other disorders such as specific phobia, panic disorder, and for aggression in patients with psychosis, acquired brain injury, or intellectual disability. Most of the evidence on the role of BBs in psychiatry is as adjunctive treatment for management of somatic symptoms rather than as monotherapy. Outside of performance anxiety and akathisia, the role of BBs in psychiatry has not been subjected to careful study, and further investigative trials are needed.
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Abstract
BACKGROUND Autism spectrum disorder (ASD) is a neurodevelopmental disorder characterized by markedly impaired social interaction, impaired communication, and restricted/repetitive patterns of behavior, interests, and activities. In addition to challenges caused by core symptoms, maladaptive behaviors such as aggression can be associated with ASD and can further disrupt functioning and quality of life. For adults with ASD, these behaviors can portend adverse outcomes (e.g., harm to others or to the individual with ASD, hindering of employment opportunities, criminal justice system involvement). This article reviews the scientific literature to provide an update on evidence-based interventions for aggression in adults with ASD. METHOD A search of the electronic databases CINAHL, EMBASE, and PsycINFO was conducted using relevant search terms. After reviewing titles, abstracts, full-length articles, and reference lists, 70 articles were identified and reviewed. RESULTS The strongest (controlled trial) evidence suggests beneficial effects of risperidone, propranolol, fluvoxamine, vigorous aerobic exercise, and dextromethorphan/quinidine for treating aggression in adults with ASD, with lower levels of evidence supporting behavioral interventions, multisensory environments, yokukansan, and other treatments. CONCLUSIONS Additional randomized, controlled trials using consistent methodology that adequately addresses sources of bias are needed to determine which treatments are reliably effective in addressing aggression in adults with ASD. In the meantime, considering efficacy and adverse effect/long-term risk profiles, a practical approach could start with functional assessment-informed behavioral interventions along with encouragement of regular, vigorous aerobic exercise to target aggression in adults with ASD, with pharmacotherapy employed if these interventions are unavailable or inadequate based on symptom acuity.
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Affiliation(s)
- David S. Im
- From the University of Michigan Hospital, Department of Psychiatry, University of Michigan Medical School
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10
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The Safety and Effectiveness of High-Dose Propranolol as a Treatment for Challenging Behaviors in Individuals With Autism Spectrum Disorders. J Clin Psychopharmacol 2020; 40:122-129. [PMID: 32134849 DOI: 10.1097/jcp.0000000000001175] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
PURPOSE/BACKGROUND Individuals with autism spectrum disorders present with social communication deficits and a rigid adherence to sameness. Along with these symptoms, many individuals also present with severe challenging behaviors that place themselves as well as their families and communities at risk for injury. For these individuals, new and effective treatments are acutely needed. Propranolol has been used worldwide for over 50 years. Its primary indication is for hypertension, but there is evidence that, at higher doses, propranolol inhibits rage and anger through its effects on the central nervous system. This effect has been demonstrated in a variety of neuropsychiatric disorders. METHODS/PROCEDURES Here, we present 46 retrospective analyses of clinical cases that were followed by a psychiatrist. Propranolol was prescribed as an add-on to the patients' existing medications. The doses ranged from 120 to 960 mg per day (mean = 462 mg). FINDINGS/RESULTS Thirty-nine (85%) of 46 patients were found to be much improved or very much improved on the physician-rated Clinical Global Impression Improvement scale. There were few side effects noted, with only 2 subjects unable to tolerate the propranolol. IMPLICATIONS/CONCLUSIONS It appears that high-dose propranolol can be given safely with minimal adverse cardiovascular problems, provided that close clinical monitoring is maintained. A more rigorous clinical trial is needed to elucidate and verify its clinical utility, clinical practice parameters, and the effects of propranolol as a monotherapy versus as an add-on to the patient's existing medication regimen.
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Robb AS, Schwabe S, Ceresoli-Borroni G, Nasser A, Yu C, Marcus R, Candler SA, Findling RL. A proposed anti-maladaptive aggression agent classification: improving our approach to treating impulsive aggression. Postgrad Med 2019; 131:129-137. [PMID: 30678534 DOI: 10.1080/00325481.2019.1574401] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Proper drug categorization enables clinicians to readily identify the agents most appropriate for patients in need. Currently, patients with maladaptive aggression do not all always fall into a single existing diagnostic or treatment category. Such is the case for those with impulsive aggression (IA). IA is an associated feature of numerous neuropsychiatric disorders, and can be described as eruptive, aggressive behavior or a 'short fuse'. Although agents from a broad spectrum of drug classes have been used to treat maladaptive aggression, few have been tested distinctly in patients with IA, and there is no drug specifically indicated by the US Food and Drug Administration (US FDA) for IA. Further, current treatments often fail to sufficiently treat IA symptomatology. These issues create an unclear and inadequate treatment path for patients. Here we will propose the establishment of a class of anti-maladaptive aggression agents to begin addressing this clinical issue. The development of such a class would unify the various drugs currently used to treat maladaptive aggression and streamline the treatment approach towards IA. As an important case example of the range of candidate drugs that could fit into a new anti-maladaptive aggression agent category, we will review an investigational IA pharmacotherapy. SPN-810 (extended-release molindone) is currently being investigated as a novel treatment for children with IA and ADHD. Based on these studies we will review how SPN-810 may be well suited for a new, anti-maladaptive aggression drug class and more precisely, a proposed subgroup of IA modulators. The goal of this review is to begin improving the identification of and therapeutic approach for maladaptive aggression as well as IA through more precise anti-maladaptive aggression agent categorization.
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Affiliation(s)
- Adelaide S Robb
- a Psychology and Behavioral Health , Children's National Medical Center , Washington , DC , USA
| | - Stefan Schwabe
- b Research & Development , Supernus Pharmaceuticals, Inc. , Rockville , MD , USA
| | | | - Azmi Nasser
- c Clinical Research , Supernus Pharmaceuticals, Inc. , Rockville , MD , USA
| | - Chungping Yu
- d Preclinical DMPK and Pharmacology , Supernus Pharmaceuticals, Inc. , Rockville , MD , USA
| | - Ronald Marcus
- c Clinical Research , Supernus Pharmaceuticals, Inc. , Rockville , MD , USA
| | - Shawn A Candler
- e Medical Affairs , Supernus Pharmaceuticals, Inc. , Rockville , MD , USA
| | - Robert L Findling
- f Psychiatry and Behavioral Sciences , Johns Hopkins University , Baltimore , MD , USA.,g Psychiatric Services and Research , Kennedy Krieger Institute , Baltimore , MD , USA
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London EB. Neuromodulation and a Reconceptualization of Autism Spectrum Disorders: Using the Locus Coeruleus Functioning as an Exemplar. Front Neurol 2018; 9:1120. [PMID: 30619071 PMCID: PMC6305710 DOI: 10.3389/fneur.2018.01120] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Accepted: 12/06/2018] [Indexed: 12/27/2022] Open
Abstract
The Autism Spectrum Disorders (ASD) are a heterogeneous group of developmental disorders. Although, ASD can be reliably diagnosed, the etiology, pathophysiology, and treatment targets remain poorly characterized. While there are many atypical findings in anatomy, genetics, connectivity, and other biologic parameters, there remains no discreet hypothesis to explain the core signs as well as the very frequent comorbidities. Due to this, designing targets for treatments can only be done by assuming each symptom is a result of a discreet abnormality which is likely not the case. Neuronal circuity remains a major focus of research but rarely taking into account the functioning of the brain is highly dependent on various systems, including the neuromodulatory substances originating in the midbrain. A hypothesis is presented which explores the possibility of explaining many of the symptoms found in ASD in terms of inefficient neuromodulation using the functioning of the locus coeruleus and norepinephrine (LC/NE) as exemplars. The basic science of LC/NE is reviewed. Several functions found to be impaired in ASD including learning, attention, sensory processing, emotional regulation, autonomic functioning, adaptive and repetitive behaviors, sleep, language acquisition, initiation, and prompt dependency are examined in terms of the functioning of the LC/NE system. Suggestions about possible treatment directions are explored.
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Affiliation(s)
- Eric B. London
- Institute for Basic Research in Developmental Disabilities, Staten Island, NY, United States
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Gurnani T, Ivanov I, Newcorn JH. Pharmacotherapy of Aggression in Child and Adolescent Psychiatric Disorders. J Child Adolesc Psychopharmacol 2016; 26:65-73. [PMID: 26881859 DOI: 10.1089/cap.2015.0167] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Aggression is a common, yet complex, behavioral complaint, and a frequent indication for referral to child and adolescent psychiatrist treatment. This article reviews the evidence supporting pharmacotherapy of aggression in youth, with a primary focus on impulsive aggression (the primary indication for this intervention). Relevant diagnostic considerations and consensus guidelines are discussed. METHODS Articles examining the role of medications in the treatment of aggression in youth with pathological aggression were identified using PubMed and MEDLINE® databases over the past 15 years (2000-2015); selected articles published prior to 2000 and deemed to be of high relevance were searched and also included. Search terms included: Aggression, aggressive, disruptive behavior, conduct, youth, children, and adolescents. Cited references were also searched for relevant articles. RESULTS There are a number of evidence-based medication treatments for aggression, which are generally best considered in the context of differential diagnosis and ongoing evidence-based psychosocial interventions. Impulsive aggression is generally considered the type of aggression most amenable to medication, but other aggression subtypes may also possibly respond to treatment. Medication classes with positive evidence include the psychostimulants and α-2 agonists (in the presence of attention-deficit/hyperactivity disorder [ADHD] and/or disruptive behavior disorders), mood stabilizing agents, and atypical antipsychotics. Published guidelines recommend systematic and adequate trials of medications in sequential order, to optimize response and minimize polypharmacy. Guidelines for safety monitoring are available for many of the medications used for aggression in youth, and are also discussed. CONCLUSIONS Aggression in children carries a high risk of poor outcomes, and, therefore, a better understanding of treatment options is a high priority. The available literature points to the importance of identifying the underlying disorder, when possible, and using this information to guide treatment selection. Future studies are needed to better inform the treatment of aggression across disorders, and the treatment of different aggression subtypes.
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Affiliation(s)
- Tina Gurnani
- 1 Department of Psychiatry, Mount Sinai-St. Luke's Hospital Center , New York, New York
| | - Iliyan Ivanov
- 1 Department of Psychiatry, Mount Sinai-St. Luke's Hospital Center , New York, New York.,2 Department of Psychiatry, Icahn School of Medicine at Mount Sinai , New York, New York
| | - Jeffrey H Newcorn
- 2 Department of Psychiatry, Icahn School of Medicine at Mount Sinai , New York, New York
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Abstract
Autism spectrum disorder is often comorbid with behavioral disturbances such as irritability, aggression and hyperactivity. Throughout the mid 2000s, several large-scale controlled clinical trials were published leading to the approval of two medications (aripiprazole and risperidone) for treatment of irritability in this condition. This review serves as an update regarding new research findings regarding psychopharmacology for children and adolescents with ASD. In summary, the past five years have yielded no further approved medications with ASD as a primary indication. Important new research results include 1) long-term safety and efficacy data (52 week) regarding treatment with aripiprazole for irritability, 2) consensus regarding potential harm from SSRIs for treatment of repetitive behaviors in children/ adolescents with ASD, 3) a randomized controlled trial showing modest benefits from atomoxetine on hyperactivity, 4) many novel agents currently under investigation.
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