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Pope E, Lara-Corrales I, Sibbald C, Liy-Wong C, Kanigsberg N, Drolet B, Ma J. Noninferiority and Safety of Nadolol vs Propranolol in Infants With Infantile Hemangioma: A Randomized Clinical Trial. JAMA Pediatr 2022; 176:34-41. [PMID: 34747977 PMCID: PMC8576629 DOI: 10.1001/jamapediatrics.2021.4565] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Propranolol for infantile hemangiomas (IH) has been shown to be effective and relatively safe. However, other less lipophilic β-blockers, such as nadolol, may be preferable in individuals who experience propranolol unresponsiveness or adverse events. OBJECTIVE To document the noninferiority and safety of oral nadolol compared with oral propranolol in infants with IH. DESIGN, SETTING, AND PARTICIPANTS This double-blind noninferiority prospective study with a noninferiority margin of 10% compared propranolol with nadolol in infants aged 1 to 6 months with problematic IH. The study was conducted in 2 academic pediatric dermatology centers in Canada between 2016 and 2020. Infants aged 1 to 6 months with a hemangioma greater than 1.5 cm on the face or 3 cm or greater on another body part causing or with potential to cause functional impairment or cosmetic disfigurement. INTERVENTIONS Oral propranolol and nadolol in escalating doses up to 2 mg/kg/d. MAIN OUTCOMES AND MEASURE Between-group differences comparing changes in the bulk (size and extent) and color of the IH at week 24 with baseline using a 100-mm visual analog scale. RESULTS The study included 71 patients. Of these, 36 were treated with propranolol. The mean (SD) age in this group was 3.1 (1.4) months, and 31 individuals (86%) were female. Thirty-five infants were treated with nadolol. The mean (SD) age in this group was 3.2 (1.6) months, and 26 individuals (74%) were female. The difference in IH between groups by t test was 8.8 (95% CI, 2.7-14.9) for size and 17.1 (95% CI, 7.2-30.0) for color in favor of the nadolol group, demonstrating that nadolol was noninferior to propranolol. Similar differences were noted at 52 weeks: 6.0 (95% CI, 1.9-10.1) and 10.1 (95% CI, 2.9-17.4) for size and color improvement, respectively. For each doubling of time unit (week), the coefficient of involution was 2.4 (95% CI, 0.5-4.4) higher with nadolol compared with propranolol. Safety data were similar between the 2 interventions. CONCLUSIONS AND RELEVANCE Oral nadolol was noninferior to oral propranolol, indicating it may be an efficacious and safe alternative in cases of propranolol unresponsiveness or adverse events, or when faster involution is required. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02505971.
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Affiliation(s)
- Elena Pope
- Division of Pediatric Dermatology, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Irene Lara-Corrales
- Division of Pediatric Dermatology, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Cathryn Sibbald
- Division of Pediatric Dermatology, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Carmen Liy-Wong
- Division of Dermatology and Rheumatology, Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
| | - Nordau Kanigsberg
- Division of Dermatology and Rheumatology, Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
| | - Beth Drolet
- Department of Dermatology, University of Wisconsin–Madison
| | - Jin Ma
- Biostatistics Research Unit, University Health Network, Toronto, Ontario, Canada
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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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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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ayaydın H, Kılıçaslan F. Zihinsel Engelliliği Olan Bir Ergende Düşük Doz Propranolol ile Agresyonun Başarılı Tedavisi: Bir Olgu Sunumu. MUSTAFA KEMAL ÜNIVERSITESI TIP DERGISI 2017. [DOI: 10.17944/mkutfd.345933] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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Abstract
PURPOSE OF REVIEW Psychotropic medications are commonly prescribed to people with intellectual disability. We reviewed current evidence-based pharmacotherapy options and recent updates to guide clinicians in their medication management plans. RECENT FINDINGS Antipsychotics, particularly risperidone, appear to be effective in reducing problem behaviors in children with intellectual disability. Evidence in adults is inconclusive. Methylphenidate appears to be effective, and α-agonists appear promising in reducing attention-deficit hyperactivity disorder symptoms. Lithium might be effective in reducing aggression. Evidence is limited to support the use of antiepileptic drugs, anxiolytics, and naltrexone for management of problem behaviors. Antidepressants may be poorly tolerated and might not be effective in reducing repetitive/stereotypic behaviors.In recent trials, glutamatergic and GABAergic agents for fragile X syndrome, and acetylcholinesterase inhibitors for Down's syndrome, failed to show efficacy. Growth hormone treatment might improve cognition and behavior in Prader-Willi syndrome population. Results from oxytocin trials on social behaviors are inconclusive albeit promising. Melatonin appears to improve sleep. Most trials of dietary supplements did not show benefits. SUMMARY Evidence-based pharmacotherapy options in people with intellectual disability are limited, and many agents can cause substantial adverse events. For this reason, clinicians should consider pharmacotherapy as only a part of comprehensive treatment, and regularly assess drug effects, adverse events, and the feasibility of decreasing dose or withdrawing medications.
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Winter PR, Itinteang T, Leadbitter P, Tan ST. PHACE syndrome--clinical features, aetiology and management. Acta Paediatr 2016; 105:145-53. [PMID: 26469095 DOI: 10.1111/apa.13242] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Revised: 09/25/2015] [Accepted: 10/12/2015] [Indexed: 02/06/2023]
Abstract
UNLABELLED PHACE syndrome comprises a spectrum of anomalies including posterior fossa malformations, haemangioma, arterial anomalies, cardiac defects and eye anomalies. PHACE should be considered in any patient with a large facial segmental infantile haemangioma (IH), and multidisciplinary management is crucial. Low-dose propranolol is effectively for the treatment of IH associated with PHACE syndrome. Recent evidence suggests IH is comprised of mesoderm-derived haemogenic endothelium. CONCLUSION The embryonic developmental anomaly nature of IH provides an insight into the origin of PHACE syndrome.
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Affiliation(s)
| | | | - Phillip Leadbitter
- Gillies McIndoe Research Institute; Wellington New Zealand
- Centre for the Study & Treatment of Vascular Birthmarks; Wellington Regional Plastic; Maxillofacial & Burns Unit; Wellington New Zealand
- Department of Paediatrics; Hutt Hospital; Wellington New Zealand
| | - Swee T. Tan
- Gillies McIndoe Research Institute; Wellington New Zealand
- Centre for the Study & Treatment of Vascular Birthmarks; Wellington Regional Plastic; Maxillofacial & Burns Unit; Wellington New Zealand
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Randhawa HK, Sibbald C, Garcia Romero MT, Pope E. Oral Nadolol for the Treatment of Infantile Hemangiomas: A Single-Institution Retrospective Cohort Study. Pediatr Dermatol 2015. [PMID: 26215612 DOI: 10.1111/pde.12655] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND Beta-blockers have become the treatment of choice for problematic infantile hemangiomas (IHs). Nadolol, a nonselective beta-blocker with potential dosing advantages and a better safety profile than that of other beta-blockers, has been studied as an alternative therapeutic option. Our objective was to characterize the efficacy and safety of oral nadolol in the treatment of proliferating IHs. METHODS A retrospective cohort study was conducted at the Hospital for Sick Children between February 2010 and April 2012 in patients treated with nadolol for proliferating IHs causing functional impairment or cosmetic disfigurement. The primary outcome was the percentage involution measured independently by two assessors who scored changes in the extent of IHs by comparing serial photographs using a 100-mm visual analogue scale (VAS), on which 5 mm represented 10% change. RESULTS Forty-four patients treated with nadolol for IHs with adequate photographic documentation were identified. The median age at presentation was 4.5 months (interquartile range 1.5-7.9 mos). There was a mean improvement of 91.8 ± 11.1%. At least 50% improvement was noted in 42 (95%) patients and 75% improvement in 39 (89%) patients. The mean time to 50% and 75% improvement was 2.9 and 3.7 months, respectively. Analysis of variance showed that younger age at the time of treatment start was associated with a higher mean VAS score (% involution) (p < 0.05). Treatment duration (mean 9.5 ± 5.6 months) had no significant effect on VAS score. Test of interobserver correlation showed good agreement (intraclass correlation coefficient = 0.86, p = 0.001). CONCLUSIONS Oral nadolol is efficacious in patients with problematic IHs. Further large-scale prospective comparative studies are warranted to compare nadolol with other beta-blockers.
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Affiliation(s)
- Harkamal Kaur Randhawa
- Section of Dermatology, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Cathryn Sibbald
- Section of Dermatology, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | | | - Elena Pope
- Section of Dermatology, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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Ward F, Tharian P, Roy M, Deb S, Unwin GL. Efficacy of beta blockers in the management of problem behaviours in people with intellectual disabilities: a systematic review. RESEARCH IN DEVELOPMENTAL DISABILITIES 2013; 34:4293-4303. [PMID: 24171827 DOI: 10.1016/j.ridd.2013.08.015] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/05/2013] [Accepted: 08/15/2013] [Indexed: 06/02/2023]
Abstract
Both medication and non-medication based strategies are used in the management of problem behaviours in individuals with intellectual disabilities. Beta-adrenoceptor blocking medications are one group of drugs used for this purpose. However, despite its regular use, the evidence for the efficacy of these drugs for in this context is lacking. A systematic review was conducted to establish the research evidence for the efficacy of beta blockers in problem behaviours in adults and children with intellectual disabilities. Although the research identified supported the efficacy of beta blockers for this indication the overall quality of studies identified was poor and no randomised controlled trials were identified. There is a need for more robust research into the use of beta blockers for people with intellectual disabilities who show problem behaviours.
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Affiliation(s)
- Frances Ward
- Southern Health NHS Foundation Trust, United Kingdom.
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Pope E, Chakkittakandiyil A, Lara-Corrales I, Maki E, Weinstein M. Expanding the therapeutic repertoire of infantile haemangiomas: cohort-blinded study of oral nadolol compared with propranolol. Br J Dermatol 2012; 168:222-4. [PMID: 22762503 DOI: 10.1111/j.1365-2133.2012.11131.x] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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Ulloa RE, Nicolini H, Avila M, Fernández-Guasti A. Randomized controlled pilot study of quetiapine in the treatment of adolescent conduct disorder. J Child Adolesc Psychopharmacol 2008; 18:140-56. [PMID: 17343556 DOI: 10.1089/cap.2006.0007] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE The aim of this study was to examine whether quetiapine is superior to placebo in the treatment of adolescents with conduct disorder. METHODS This was a 7-week, randomized, double-blind, placebo-controlled pilot study with two parallel arms. Nine youths were randomly assigned to receive quetiapine, and 10 youths were randomly assigned to receive placebo. Patients were assessed weekly throughout the trial. Quetiapine was dosed twice daily, and medications could be titrated flexibly through the end of study week 5. The dose was fixed for the final 2 weeks of the study. The primary outcome measures were the clinician-assessed Clinical Global Impressions-Severity (CGI-S) and-Improvement (CGI-I) scales. Secondary outcome measures included parent-assessed quality of life, the overt aggression scale (OAS), and the conduct problems subscale of the Conners' Parent Rating Scale (CPRS-CP). RESULTS The final mean dose of quetiapine was 294 +/- 78 mg/day (range 200-600 mg/day). Quetiapine was superior to placebo on all clinician-assessed measures and on the parent-assessed quality of life rating scale. No differences were found on the parent-completed OAS and CPRS-CP. Quetiapine was well tolerated. One patient randomized to quetiapine developed akathisia, requiring medication discontinuation. No other extrapyramidal side effects occurred in patients receiving active drug. CONCLUSIONS This methodologically controlled pilot study provides data that quetiapine may have efficacy in the treatment of adolescents with conduct disorder. Because of the preliminary nature of the study, further research with larger samples is needed to confirm these findings.
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Affiliation(s)
- Rosa-Elena Ulloa
- Hospital Psiquiátrico Infantil Dr. Juan N. Navarro, Mexico City, Mexico.
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Abstract
Pediatricians have an important role not only in early recognition and evaluation of autism spectrum disorders but also in chronic management of these disorders. The primary goals of treatment are to maximize the child's ultimate functional independence and quality of life by minimizing the core autism spectrum disorder features, facilitating development and learning, promoting socialization, reducing maladaptive behaviors, and educating and supporting families. To assist pediatricians in educating families and guiding them toward empirically supported interventions for their children, this report reviews the educational strategies and associated therapies that are the primary treatments for children with autism spectrum disorders. Optimization of health care is likely to have a positive effect on habilitative progress, functional outcome, and quality of life; therefore, important issues, such as management of associated medical problems, pharmacologic and nonpharmacologic intervention for challenging behaviors or coexisting mental health conditions, and use of complementary and alternative medical treatments, are also addressed.
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Abstract
The use of pharmacologic agents as a component of treatment for children and adults with autism spectrum disorders is common and a substantial body of literature describing controlled and open-label clinical trials now exists to guide clinical practice. Empiric evidence of efficacy of risperidone, methylphenidate and some selective serotonin re-uptake inhibitors for maladaptive behaviors commonly associated with autism spectrum disorders has increased substantially in recent years. Preliminary controlled trials of valproate, atomoxetine, alpha-2 adrenergic agonists and olanzapine are promising. In addition to traditional psychotropic medications, investigators have examined the potential role of a variety of agents with glutamatergic or cholinergic mechanisms, and the results warrant further investigation. Although psychotropic medications are effective in treating some important associated behaviors, evidence of significant impact on the core features of autism spectrum disorders is very limited.
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Affiliation(s)
- Scott M Myers
- Neurodevelopmental Pediatrician, Geisinger Health System Assistant Professor of Pediatrics, Jefferson Medical College Geisinger Medical Center, Danville, PA 17822-1339, USA.
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Abstract
This article first reviews ways to assess children in the justice system who may benefit from psychopharmacologic treatments. Second, it summarizes the emerging understanding of the nature of aggression and violence and the utility of using the schema of reactive ("hot") and proactive ("cold") aggression as a way to consider pharmacologic options. Third, it summarizes the current published studies on the treatment of conduct disorder, which roughly corresponds to the population of children in the juvenile justice system. Finally, it examines the ways that different classes of medications might be considered when approaching juvenile delinquents and the ways that psychopharmacology could be used as part of an overall treatment plan.
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Affiliation(s)
- Marie V Soller
- Stanford University School of Medicine, Palo Alto, CA, USA
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Connor DF, Harrison RJ, Melloni, Jr. RH. Biogenic amines and the psychopharmacology of aggression. Expert Opin Ther Pat 2005. [DOI: 10.1517/13543776.8.4.349] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Pappadopulos EA, Tate Guelzow B, Wong C, Ortega M, Jensen PS. A review of the growing evidence base for pediatric psychopharmacology. Child Adolesc Psychiatr Clin N Am 2004; 13:817-55, vi. [PMID: 15380785 DOI: 10.1016/j.chc.2004.04.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
This article provides an update of pediatric psychopharmacologic treatment evidence and focuses on six classes of medications in pediatric populations: psychostimulants, mood stabilizers, SSRIs, tricyclic antidepressants, antipsychotic agents, and other agents. The evidence is organized by disorder so that it is most useful to practicing clinicians. We begin each section with a brief introduction and summary of the findings published before January 1998. Priority is given to clinical trials that use random assignment and use of a comparison group (ie, placebo-control, head-to-head comparison, or cross-over design). Serious concerns remain about the efficacy and safety of many of these agents for use in children and adolescents. While a great progress is being made, there is clearly much work left to be done.
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Affiliation(s)
- Elizabeth A Pappadopulos
- Center for the Advancement of Children's Mental Health, Columbia University College of Physicians and Surgeons/New York State Psychiatric Institute, 1051 Riverside Drive, Unite 78, New York, NY 10032, USA
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Abstract
Knowledge regarding psychopharmacology is increasingly based on clinical trials and rational algorithms. Medications are increasingly regarded as useful adjuncts in the treatment of maladaptive aggression, whether it appears as a target symptom or as a complication of a whole range of psychopathology. Properly integrated into a treatment package that uses psychotherapies and environmental manipulation, medications can provide relief from one of the most destructive forms of psychopathology. Still, more controlled clinical trials are needed, especially those comparing active interventions and those testing the synergistic and antagonistic effects of different treatment modalities.
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Affiliation(s)
- Steven Ruths
- University of California, San Diego Children's Hospital Program, San Diego, CA, USA
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Abstract
A variety of compounds with a common noradrenergic/dopaminergic activity have shown documented anti-Attention-Deficit/Hyperactivity Disorder (ADHD) activity. There is a substantial body of literature documenting the efficacy of tricyclic antidepressants on ADHD in over 1,000 subjects. There is an equally large database on the efficacy of the specific norepinephrlne reuptake inhibitor, atomoxetine, of greater than 2,000 Individuals. In addition, the atypical antidepressant buproplon also has been documented to be effective in the treatment of ADHD in controlled clinical trials. Despite wide use, the scientific base supporting the efficacy of alpha-2, noradrenergic agonists is somewhat limited. Several lines of evidence provide preliminary support for the potential benefits of cholinergic cognitive enhandng drugs, such as anticholinesterase inhibitors (tacrine, donepezil) as well as novel nicotinic analogues (ABT-418). Despite these promising results, more research is needed on alternative pharmacological treatments for the treatment of ADHD.
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Affiliation(s)
- T Spencer
- Pediatric Psychopharmacology Unit, Psychiatry Service at Massachusetts General Hospital, Boston 02114, USA
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Schur SB, Sikich L, Findling RL, Malone RP, Crismon ML, Derivan A, Macintyre Ii JC, Pappadopulos E, Greenhill L, Schooler N, Van Orden K, Jensen PS. Treatment recommendations for the use of antipsychotics for aggressive youth (TRAAY). Part I: a review. J Am Acad Child Adolesc Psychiatry 2003; 42:132-44. [PMID: 12544173 DOI: 10.1097/00004583-200302000-00007] [Citation(s) in RCA: 106] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To review the evidence for the safety and efficacy of nonpharmacological and pharmacological treatments for aggression in children and adolescents. METHOD and searches (1990-present) were conducted for double-blind, placebo-controlled studies of atypical antipsychotics for aggression and for literature on the use of other pharmacological agents and psychosocial interventions for aggression. Case reports and adult literature regarding the safety of atypical antipsychotics were used where controlled data for youth were lacking. RESULTS Controlled data on the treatment of aggression in youth is scarce. Psychosocial interventions may be effective alone or in combination with pharmacological treatments. Psychotropic agents (e.g., stimulants, mood stabilizers, beta-blockers) have also been shown to have limited efficacy in reducing aggression. Antipsychotics, particularly the atypical antipsychotics, show substantial efficacy in the treatment of aggression in selected pediatric populations. Atypical antipsychotics are generally associated with fewer extrapyramidal symptoms than are typical antipsychotics. CONCLUSIONS Psychosocial interventions and atypical antipsychotics are promising treatments for aggression in youth. Double-blind studies should examine the safety and efficacy of atypical antipsychotics compared to each other and to medications from other classes, the efficacy of specific medications for different subtypes of aggression, combining various psychotropic medications, optimal dosages, and long-term safety.
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Affiliation(s)
- Sarah B Schur
- Center for the Advancement of Children's Mental Health, Columbia University/New York State Psychiatric Institute, NY 10032, USA
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Towbin KE. Strategies for pharmacologic treatment of high functioning autism and Asperger syndrome. Child Adolesc Psychiatr Clin N Am 2003; 12:23-45. [PMID: 12512397 DOI: 10.1016/s1056-4993(02)00049-4] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
The treatment of complex, polymorphous disorders like HFA/AS always brings a particular challenge to pharmacotherapy. Additionally, the specific characteristics presented by HFA/AS introduce unique complications to patient care and place unusual demands on a clinician's skill and experience. To provide safe and effective treatment, the clinician must understand the core features of the disorder and the manifestations of the condition in his or her patient. Furthermore, a thorough understanding of the family, school, and community resources and limitations is necessary. Once an assessment has been made, focusing on target symptoms provides a crucial framework for care. Knowing manifestations of symptoms and characterizing their distribution and behavior in that patient is most important. For patients with HFA/AS it is particularly essential to coordinate behavioral and pharmacologic objectives. The target symptoms should be tracked carefully and placed into a priority system that is based on the risks and disability they create for the patient. The skill of pharmacotherapy also means setting out realistic expectations, keeping track of the larger systems of care at school and home, and collaboration with parents and care providers. There is an expanding range and pace of biologic and intervention research into HFA/AS. The genetic work has produced exciting leads that are likely to be helpful to future generations [82-84], but the task of clinicians is to tend to today's patients. As we discover more about the complex neural circuitry subserving repetitive behaviors, reward systems, and social cognition, there are good reasons to believe our treatments will become more sophisticated and specific. Psychopharmacology is also moving to design medications that target more specific populations of receptor and brain functions. This is likely to produce medicines that have fewer side effects, are more effective, and are more symptom-specific. Pharmacotherapy is not the ultimate treatment for HFA/AS but it has a definite place. Medication can be a critical element in a comprehensive treatment plan. There is a wider range of medications with more specific biologic effects than ever before. For patients with HFA/AS these newer agents are safer and less disruptive. When paired with clinicians who are becoming more skilled at recognizing and managing symptoms, patients have a greater opportunity to reach their potential and lead pleasurable lives.
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Affiliation(s)
- Kenneth E Towbin
- Departments of Psychiatry and Behavioral Sciences, and Pediatrics, George Washington University School of Medicine, Children's National Medical Center, 111 Michigan Avenue NW, Washington, DC 20010, USA.
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Baving L, Schmidt MH. [Evaluated treatment approaches in child and adolescent psychiatry I]. ZEITSCHRIFT FUR KINDER-UND JUGENDPSYCHIATRIE UND PSYCHOTHERAPIE 2001. [PMID: 11524896 DOI: 10.1024//1422-4917.29.3.189] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
OBJECTIVES The principle of evidence-based medicine is to integrate data concerning the efficacy of interventions into clinical practice. This article assesses the level of evaluation of psychosocial, psychopharmacological and combined interventions for mental disorders in childhood and adolescence (autistic disorders, hyperkinetic disorders, conduct disorders, tic disorders, enuresis, and encopresis). METHODS Three different levels of evaluation were defined for both psychosocial and psychopharmacological interventions: A (> or = 2 randomized controlled studies), B (1 randomized controlled study), and C (open studies and case studies). The level of evaluation was judged on the basis of original papers found in a comprehensive literature search. RESULTS For most disorders presented in this article there are several A-level treatments. The efficacy of both psychosocial and psychopharmacological interventions that target specific problem behaviors or symptoms, respectively, has been repeatedly demonstrated with regard to autistic disorders. Many studies have evaluated treatment approaches for hyperkinetic disorders and conduct disorders. With regard to the treatment of tic disorders in children and adolescents, far more studies evaluated the efficacy of pharmacotherapy than of psychotherapy. CONCLUSIONS Further research should compare the efficacy of different treatment approaches, examine specific and differential treatment effects and investigate combined treatment approaches.
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Affiliation(s)
- L Baving
- Klinik für Kinder- und Jugendpsychiatrie, Otto-von-Guericke-Universität Magdeburg.
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Abstract
We reviewed the literature of medication trials in ADHD to evaluate the scope of the available non-stimulant treatments. A variety of compounds with a common noradrenergic/ dopaminergic activity have shown documented anti-ADHD activity. There is a substantial body of literature documenting the efficacy of tricyclic antidepressants on ADHD in over 1,000 subjects. In addition, the atypical antidepressant bupropion and the novel noradrenergic specific antidepressant tomoxetine have also been documented to be effective in the treatment of ADHD in controlled clinical trials. Despite wide use, the scientific base supporting the efficacy of alpha-2, noradrenergic agonists continues to be limited. Several lines of evidence provide preliminary support for the potential benefits of cholinergic cognitive enhancing drugs in such as anticholinesterase inhibitors (tacrine, donepezil) as well as novel nicotinic analogues (ABT-418). Despite these promising results, more research is needed on alternative pharmacologic treatments for the treatment of ADHD.
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Affiliation(s)
- J Biederman
- Pediatric Psychopharmacology Unit, Massachusetts General Hospital, Boston, MA 02114, USA
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