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Abstract
INTRODUCTION Cyclic vomiting syndrome (CVS) is a potentially exhausting disorder and has an adverse impact on quality of life, but it is poorly recognized and is always misdiagnosed leading to a diagnostic delay of several years, especially in adults. PATIENT CONCERNS We report a case of a 32-year-old woman with recurrent severe nausea, vomiting, and abdominal pain, and repeated visits to the emergency department or the outpatient department for 4 years. Each time she was diagnosed with gastroenteritis or gastritis, and recovered after supportive treatment including antiemetics, maintenance of water and electrolyte balance, and a proton pump inhibitor. DIAGNOSIS Laboratory examinations, gastroenteroscopy, chest and abdominal computed tomography, and brain magnetic resonance imaging all failed to reveal abnormalities that would explain her symptoms. Based on typical symptoms and the exclusion of other diseases associated with repeated vomiting, the diagnosis was made as CVS. INTERVENTIONS She was given orally amitriptyline, 50 mg per night, and olanzapine, 1.25 mg per night. OUTCOMES The treatment was effective in inducing remission, and symptoms did not recur after treatment. The treatment lasted for 2 months and stopped. Her symptoms did not recur over the 10-month follow up. CONCLUSION CVS is not rare in adults, but its diagnosis is usually delayed due to poor recognition of the condition. Clinician awareness of CVS should be enhanced to improve early diagnosis.Core tip: Cyclic vomiting syndrome has a tremendous impact on the quality of life, but it is poorly recognized and is always misdiagnosed leading to a diagnostic delay of several years, especially in adults. The article presented a case report of cyclic vomiting syndrome of adult; we hope the article will attribute to increased awareness of physician and reduce delayed diagnosis.
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Affiliation(s)
- Cuilan Tang
- Department of Infectious Diseases, The Second Affiliated Hospital, Zhejiang University School of Medicine, No. 88 Jiefang Road, Hangzhou 310009
| | - Ning Dai
- Department of Digestive Diseases, Sir Run Run Shaw Hospital (SRRSH), affiliated with the Zhejiang University School of Medicine, No. 3 East Qingchun Road, Hangzhou 310006, Zhejiang, China
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Kovacic K, Sood M, Venkatesan T. Cyclic Vomiting Syndrome in Children and Adults: What Is New in 2018? Curr Gastroenterol Rep 2018; 20:46. [PMID: 30159612 DOI: 10.1007/s11894-018-0654-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
PURPOSE OF REVIEW Cyclic vomiting syndrome (CVS) is a disabling functional gastrointestinal disorder characterized by severe vomiting episodes that alternate with symptom-free periods. The purpose of this review is to summarize current knowledge and highlight most recent data on prevalence, diagnosis, management, and impact of CVS in children and adults. RECENT FINDINGS Originally thought to be a pediatric disorder, the past decade has witnessed a considerable increase in CVS diagnosed in adults. Despite improved recognition of CVS, without a delineated pathophysiology and specific biomarker, it remains classified as a functional gastrointestinal disorder. Migraines and CVS share a common pathway based on several studies and response to migraine therapy. Recent work has begun to expand the list of comorbidities and identify plausible mechanisms and new therapeutic avenues. This review seeks to highlight best practices and novel therapies for CVS based on expert consensus and review of available literature.
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Affiliation(s)
- Katja Kovacic
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Children's Hospital of Wisconsin, Medical College of Wisconsin, 9000 W. Wisconsin Avenue, Milwaukee, WI, 53226, USA.
| | - Manu Sood
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Children's Hospital of Wisconsin, Medical College of Wisconsin, 9000 W. Wisconsin Avenue, Milwaukee, WI, 53226, USA
| | - Thangam Venkatesan
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, WI, USA
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Mancini J, Dubus JC, Jouve E, Roux JC, Franco P, Lagrue E, Castelnau P, Cances C, Chaix Y, Rougeot-Jung C, Cornu C, Desportes V, Vallée L, Bahi-Buisson N, Truillet R, Attolini L, Villard L, Blin O, Micallef J. Effect of desipramine on patients with breathing disorders in RETT syndrome. Ann Clin Transl Neurol 2017; 5:118-127. [PMID: 29468173 PMCID: PMC5817841 DOI: 10.1002/acn3.468] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Accepted: 08/21/2017] [Indexed: 12/27/2022] Open
Abstract
Objective Rett Syndrome (RTT) is a severe neurodevelopmental condition with breathing disorders, affecting around one in 10,000 female births. Desipramine, a noradrenaline reuptake inhibitor, reduced the number of apneas in Mecp2-deficient mice, a model of RTT. We planned a phase 2 trial to test its efficacy and its safety on breathing patterns in 36 girls with RTT. Methods The trial was a 6-month, multicenter, randomized, double-blind, placebo-controlled study registered with ClinicalTrials.gov, number NCT00990691. Girls diagnosed according to clinical examination and confirmed by genotyping were randomly assigned in a 1:1:1 ratio to receive 2-3 mg/kg Desipramine per day (high Desipramine), 1-2 mg/kg Desipramine per day (low Desipramine), or a placebo. The primary outcome was the change of apnea hypopnea index (AHI), defined by the number of apnea and hypopnea events per hour, assessed at 6 months from baseline. Intention-to-treat analysis was applied. Results The median change in AHI from baseline to 6 months was -31 (IQR: -37 to -11) for the high Desipramine, -17.5 (IQR: -31 to 13) for the low Desipramine, and -13 (IQR:-31 to 0) for the placebo group. We did not find any significant difference in these changes between the groups (P = 0.781). A significant inverse correlation between Desipramine plasma concentration and AHI (r = -0.44; P = 0.0002) was underlined. Interpretation This first clinical trial of desipramine did not show clinical efficacy. Although required further studies, the significant correlation between Desipramine concentrations and improvement of AHI provided additional and relevant reasons to test the noradrenergic pathway in RTT.
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Affiliation(s)
- Josette Mancini
- Neuropediatric Unit Aix Marseille University Children Hospital APHM, Timone, Neurosciences Institute Marseille France
| | - Jean-Christophe Dubus
- Pneumology Pediatric Unit Aix Marseille University Children Hospital CNRS URMITE 6236A PHM Marseille France
| | - Elisabeth Jouve
- Department of Pharmacology F-CRIN Orphan DEV Timone Neurosciences Institute Aix Marseille University CNRS INTAPHM, CIC CPCET CHU Timone Marseille France
| | | | - Patricia Franco
- Neuropediatric Ward Hypnology Unit Lyon University Civil Hospices of Lyon INSERM U628 Lyon France
| | - Emmanuelle Lagrue
- Neuropediatrics and Handicap Department Tours University INSERM, UMR U930 Imaging and Brain, CHRU Tours Tours France
| | - Pierre Castelnau
- Neuropediatrics and Handicap Department Tours University INSERM, UMR U930 Imaging and Brain, CHRU Tours Tours France
| | - Claude Cances
- Neuropediatric Unit Neuro Imaging Center Toulouse University Children Hospital CHU PURPANUMR 1214 Toulouse France
| | - Yves Chaix
- Neuropediatric Unit Neuro Imaging Center Toulouse University Children Hospital CHU PURPANUMR 1214 Toulouse France
| | - Christelle Rougeot-Jung
- Lyon University National Reference Center for Rare Diseases with Intellectual Disability HFME Hospices Civils de Lyon Lyon France.,CNRS UMR 5304 ISC Lyon France
| | - Catherine Cornu
- Department of Pharmacotoxicology Clinical Investigation Center Hospices Civils de Lyon INSERM 1407 Lyon France.,Lyon University CNRS UMR 5558 Lyon France
| | - Vincent Desportes
- Lyon University National Reference Center for Rare Diseases with Intellectual Disability HFME Hospices Civils de Lyon Lyon France.,CNRS UMR 5304 ISC Lyon France
| | - Louis Vallée
- Department of Neuropediatrics Lille North 2 University CHRU Hôpital Roger Salengro Lille France
| | - Nadia Bahi-Buisson
- Imagine Institute and INSERM UMR-1163 Embryology and Genetics of Congenital Malformations Pediatric Neurology Paris Descartes - Sorbonne Paris Cité University Necker Enfants Malades University Hospital AP-HP Paris France
| | - Romain Truillet
- Department of Pharmacology F-CRIN Orphan DEV Timone Neurosciences Institute Aix Marseille University CNRS INTAPHM, CIC CPCET CHU Timone Marseille France
| | - Laurence Attolini
- Department of Pharmacology F-CRIN Orphan DEV Timone Neurosciences Institute Aix Marseille University CNRS INTAPHM, CIC CPCET CHU Timone Marseille France
| | - Laurent Villard
- Aix Marseille University INSERM, GMGF UMR_S 910 Marseille France
| | - Olivier Blin
- Department of Pharmacology F-CRIN Orphan DEV Timone Neurosciences Institute Aix Marseille University CNRS INTAPHM, CIC CPCET CHU Timone Marseille France
| | - Joëlle Micallef
- Department of Pharmacology F-CRIN Orphan DEV Timone Neurosciences Institute Aix Marseille University CNRS INTAPHM, CIC CPCET CHU Timone Marseille France
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Rodday AM, Parsons SK, Mankiw C, Correll CU, Robb AS, Zima BT, Saunders TS, Leslie LK. Child and adolescent psychiatrists' reported monitoring behaviors for second-generation antipsychotics. J Child Adolesc Psychopharmacol 2015; 25:351-61. [PMID: 25918843 PMCID: PMC4442598 DOI: 10.1089/cap.2014.0156] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE The number of children and adolescents (hereafter referred to as "children") who have been prescribed second-generation antipsychotics (SGAs) has increased over the last decade, but little is known about monitoring practices in pediatric patients who are vulnerable to adverse effects. We examined factors associated with psychiatrists' self-reported monitoring of children who were prescribed SGAs. METHODS A survey was mailed to a national, randomly selected sample of 1600 child and adolescent psychiatrists from the American Medical Association mailing list. Using logistic regression, we tested whether psychiatrist characteristics, attitudes, and practice characteristics were associated with monitoring (baseline and/or periodic) the following: Patient history, height and weight, blood pressure, waist circumference, lipid and glucose levels, and electrocardiogram. RESULTS Among the analytic sample of 308, at least two thirds reported monitoring patient history, height and weight, blood pressure, and fasting plasma lipids and glucose; 23% reported monitoring waist circumference; and 12% reported conducting an electrocardiogram. More than one third stated that they routinely monitored thyroid levels and more than half reported monitoring complete blood count and electrolytes/blood urea nitrogen. Psychiatrists reporting that they were able to measure vital signs on site were more likely to measure height and weight. Those who reported feeling comfortable conducting a physical examination were more likely to measure blood pressure. Those answering that the risk of metabolic syndrome was low were less likely to measure blood pressure and waist circumference. Being board certified and able to measure vital signs on site were associated with more monitoring of glucose and lipid levels. Conversely, years in practice and feeling that patients were nonadherent with blood work were associated with less monitoring of glucose and lipid levels. CONCLUSIONS In this sample, inconsistent monitoring patterns of children prescribed SGAs were found. Efforts to communicate guidelines' evidence base and improve office capacity to measure and track adverse effects are needed to increase appropriate adverse effect monitoring in children who have been prescribed SGAs.
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Affiliation(s)
- Angie Mae Rodday
- The Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts.,Tufts University School of Medicine, Boston, Massachusetts
| | - Susan K. Parsons
- The Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts.,Tufts University School of Medicine, Boston, Massachusetts
| | - Catherine Mankiw
- The Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts
| | - Christoph U. Correll
- The Zucker Hillside Hospital, North Shore-LIJ Health System, Glen Oaks, New York
| | - Adelaide S. Robb
- Center for Clinical and Community Research, Children's National Health System, Washington, DC
| | - Bonnie T. Zima
- Department of Psychiatry and Biobehavioral Sciences, University of California at Los Angeles, Los Angeles, California
| | - Tully S. Saunders
- The Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts
| | - Laurel K. Leslie
- The Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts.,Tufts University School of Medicine, Boston, Massachusetts.,Floating Hospital for Children, Tufts Medical Center, Boston, Massachusetts
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Antel J, Albayrak Ö, Heusch G, Banaschewski T, Hebebrand J. Assessment of potential cardiovascular risks of methylphenidate in comparison with sibutramine: do we need a SCOUT (trial)? Eur Arch Psychiatry Clin Neurosci 2015; 265:233-47. [PMID: 25149468 DOI: 10.1007/s00406-014-0522-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2013] [Accepted: 08/01/2014] [Indexed: 12/20/2022]
Abstract
With the recent approval of methylphenidate (MPH) for treating attention-deficit/hyperactivity disorder (ADHD) in adults, the number of patients exposed will increase tremendously. The ongoing debate on the cardiovascular safety of MPH has triggered two large retrospective cohort studies in children and adolescents as well as in young to middle-aged adults. These studies looked into serious cardiovascular events (sudden cardiac death, acute myocardial infarction and stroke) as primary endpoints and concluded that MPH was safe after a mean duration of 2.1 years of follow-up in children and adolescents and mean duration of 0.33 years of current use in adults. The results are encouraging with respect to the short- and medium-term use of MPH. Without the inherent limitations of retrospective cohort studies, a prospective randomized, double-blind, placebo-controlled, multicenter trial in individuals stratified for cardiovascular risk factors would allow for an optimized risk assessment. With many millions of patients treated per year and drawing parallels to the lately discovered risks of sibutramine, another sympathomimetic with an overlapping mode of action and similar side effects on heart rate and blood pressure, we hypothesize that such a trial might be a dedicated risk mitigation strategy for public health. A critical assessment of cardiovascular side effects of MPH appears particularly warranted, because ADHD is associated with obesity, smoking and poor health in general. We summarize recent findings with the focus on cardiovascular risks of MPH in humans; we additionally analyze the limited number of rodent studies that have addressed cardiovascular risks of MPH.
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Affiliation(s)
- Jochen Antel
- Research-Unit of the Department of Child and Adolescent Psychiatry, Psychosomatics, and Psychotherapy, LVR-Klinikum Essen, University of Duisburg-Essen, IG1 Virchowstr. 171, 45147, Essen, Germany,
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6
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Nguyen M, Tharani S, Rahmani M, Shapiro M. A review of the use of clonidine as a sleep aid in the child and adolescent population. Clin Pediatr (Phila) 2014; 53:211-6. [PMID: 24027233 DOI: 10.1177/0009922813502123] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Findling RL, Cutler AJ, Saylor K, Gasior M, Hamdani M, Ferreira-Cornwell MC, Childress AC. A long-term open-label safety and effectiveness trial of lisdexamfetamine dimesylate in adolescents with attention-deficit/hyperactivity disorder. J Child Adolesc Psychopharmacol 2013; 23:11-21. [PMID: 23410138 DOI: 10.1089/cap.2011.0088] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Information on psychostimulant treatment in long-term studies for attention-deficit/hyperactivity disorder (ADHD) in adolescents is limited. This study aimed to assess the safety and effectiveness of lisdexamfetamine dimesylate (LDX) over 52 weeks in adolescents with ADHD. METHODS This open-label multicenter study enrolled eligible participants after their participation in a randomized, double-blind, placebo-controlled 4 week trial in adolescents with ADHD. Following a 4 week dose-optimization phase, participants were maintained on treatment for up to ∼48 weeks on an optimal dose. Safety assessments included treatment-emergent adverse events (TEAEs), vital signs, laboratory findings, and electrocardiograms. Effectiveness measures included the ADHD Rating Scale IV (ADHD-RS-IV; primary) and Clinical Global Impressions-Improvement (CGI-I). The Youth Quality of Life-Research Version (YQOL-R) was also included in this study; raw scores are transformed to a 0-100 point scale. RESULTS Of 269 enrolled (from the antecedent study), 265 (98.5%) were in the safety population and effectiveness population. Common TEAEs (≥5%) with LDX included upper respiratory tract infection (21.9%), decreased appetite (21.1%), headache (20.8%), decreased weight (16.2%), irritability (12.5%), insomnia (12.1%), nasopharyngitis (7.2%), influenza (6.8%), dizziness (5.3%), and dry mouth (5.3%). At end point, for all LDX doses in the overall safety population, mean (SD) increase from baseline in systolic blood pressure was 2.3 (10.53) mm Hg, diastolic blood pressure was 2.5 (8.37) mm Hg, and pulse rate was 6.3 (12.74) bpm. No clinically meaningful electrocardiogram or vital sign changes were observed. At end point with LDX treatment, the ADHD-RS-IV mean (SD) total score change from antecedent study baseline was -26.2 (9.75) (p<0.001); 87.2% of participants were improved (CGI-I=1 or 2). Baseline (antecedent study) mean (SD) YQOL-R perceptual total score was 79.8 (11.28) and increased by 3.9 (9.73) at end point (p<0.001). CONCLUSIONS LDX demonstrated a long-term safety profile similar to that of other long-acting psychostimulants and was effective, as indicated by improvements in ADHD symptoms and participant-perceived YQOL, in adolescents with ADHD. CLINICAL TRIAL REGISTRATION NCT00764868, http://www.clinicaltrials.gov/ct2/show/NCT00764868?term=SPD489-306&rank=1.
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Affiliation(s)
- Robert L Findling
- Johns Hopkins Medicine and the Kennedy Krieger Institute, Johns Hopkins University, Baltimore, MD 21287, USA.
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Cho SC, Kim BN, Cummins TDR, Kim JW, Bellgrove MA. Norepinephrine transporter -3081(A/T) and alpha-2A-adrenergic receptor MspI polymorphisms are associated with cardiovascular side effects of OROS-methylphenidate treatment. J Psychopharmacol 2012; 26:380-9. [PMID: 21628343 DOI: 10.1177/0269881111405356] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The purpose of this study was to investigate a possible association between norepinephrine genes and cardiovascular side effects of the Osmotic Controlled-Release Oral Delivery System-methylphenidate (OROS-MPH) in Korean children with attention-deficit/hyperactivity disorder (ADHD). One hundred and one children with ADHD (8.7 ± 1.7 years) were recruited from child psychiatric centers at six university hospitals in South Korea. All participants were drug-naive ADHD children treated with OROS-MPH for 12 weeks. During the treatment period the investigators titrated the OROS-MPH dosage on the basis of symptom severity and side effects. Resting heart rate (HR), diastolic blood pressure (DBP), and systolic blood pressure (SBP) were examined before and after treatment. The percentage change score (post-treatment - pretreatment/pretreatment × 100) of each parameter was calculated. Genotyping of SLC6A2 -3081(A/T) and G1287A, and alpha-2A-adrenergic receptor (ADRA2A) MspI and DraI polymorphisms was performed. Clinically significant changes were not found in cardiovascular monitoring during the course of treatment. An increase of HR after OROS-MPH treatment was found to be statistically significant (t = 3.54, p = 0.001). Changes in SBP and DBP were not significant and no specific change was found in the ECGs. However, an additive regression analysis demonstrated a significant association between SLC6A2 -3081(A/T) and percentage change in HR post-treatment (p = 0.01) after controlling for age, gender, dosage of MPH and response and baseline pulse rate. Children with ADHD having the T/T genotype of SLC6A2 showed a 12.5% increase in HR compared to baseline, whereas children with the A/T or A/A genotype showed a 3.5% and 2.5% increase after OROS-MPH treatment, respectively. There was also a significant association between the ADRA2A MspI genotype and percentage change of DBP post-treatment after controlling for age, gender, dosage of MPH and response and baseline DBP (p = 0.009). Children with ADHD having the C/C genotype of ADRA2A MspI showed an 18.5% increase in DBP compared to baseline, but children with the G/G or G/C genotype showed a 0.2% decrease after OROS-MPH treatment. The overall cardiovascular effects of OROS-MPH were modest. However, our findings show a positive association between norepinephrine-related gene polymorphisms and cardiovascular response induced by MPH in Korean children with ADHD. Consideration must be given to such children or adults with specific norepinephrine-related genotypes, especially if they show significant changes in HR or DBP after OROS-MPH administration.
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Affiliation(s)
- Soo-Churl Cho
- Division of Child and Adolescent Psychiatry, Department of Psychiatry, Seoul National University, College of Medicine, Seoul, South Korea
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Nahshoni E, Golubchik P, Glazer J, Sever J, Strasberg B, Imbar S, Shoval G, Weizman A, Zalsman G. Late potentials in the signal-averaged electrocardiogram in pre-pubertal children with ADHD, before and after methylphenidate treatment. Eur Child Adolesc Psychiatry 2012; 21:75-8. [PMID: 22160611 DOI: 10.1007/s00787-011-0233-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2011] [Accepted: 11/30/2011] [Indexed: 11/28/2022]
Abstract
Reports on sudden cardiac death (SCD) of children and adolescents treated with stimulant agents have raised concerns regarding the need for cardiovascular monitoring and risk stratification schedules. Cardiac ventricular late potentials (LPs) represent delayed ventricular activation that might predispose to fatal ventricular arrhythmias and SCD in cardiac patients. LPs have not previously been measured in children with attention deficit/hyperactivity disorder (ADHD). LPs were measured in 18 physically healthy ADHD children (5 girls and 13 boys, age 11.9 ± 2.5 years, treatment duration 2.6 ± 1.9 years) before and 2 h after oral methylphenidate administration. No significant changes were detected and LPs were found to be within normal ranges. In conclusion, this preliminary small-scale study suggests that methylphenidate in physically healthy children with ADHD was not associated with cardiac ventricular LPs, suggesting the safety of the agent in this age group.
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Affiliation(s)
- Eitan Nahshoni
- The Davidoff Cancer Center, Rabin Medical Center, Petach Tikva, Israel.
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Hammerness PG, Perrin JM, Shelley-Abrahamson R, Wilens TE. Cardiovascular risk of stimulant treatment in pediatric attention-deficit/hyperactivity disorder: update and clinical recommendations. J Am Acad Child Adolesc Psychiatry 2011; 50:978-90. [PMID: 21961773 DOI: 10.1016/j.jaac.2011.07.018] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2011] [Revised: 07/13/2011] [Accepted: 07/25/2011] [Indexed: 11/15/2022]
Abstract
OBJECTIVE This review provides an update on the cardiovascular impact of therapeutic stimulant-class medication for children and adolescents with attention-deficit/hyperactivity disorder (ADHD). METHOD Relevant clinical literature was ascertained using PubMed searches limited to human studies and the English language as of May 2011. Current practice guidelines and consensus statements also were reviewed. RESULTS Stimulant-class medications for healthy children and adolescents with ADHD are associated with mean elevations in blood pressure (≤5 mmHg) and heart rate (≤10 beats/min) without changes in electrocardiographic parameters. A subset (5-15%) of children and adolescents treated may have a greater increase in heart rate or blood pressure at a given assessment or may report a cardiovascular-type complaint during stimulant treatment. It is extremely rare for a child or adolescent receiving stimulant medication to have a serious cardiovascular event during treatment, with the risk appearing similar to groups of children not receiving stimulant medication. CONCLUSIONS Clinicians should adhere to current recommendations regarding the prescription of stimulant medications for youth with ADHD. Scientific inquiry is indicated to identify patients at heightened risk and to continue surveillance for the longer-term cardiovascular impact of these agents.
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Affiliation(s)
- Paul G Hammerness
- Clinical and Research Programs in Pediatric Psychopharmacology and Adult ADHD, Massachusetts General Hospital, and Harvard Medical School, USA.
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Bradley SJ. Anxiety and mood disorders in children and adolescents: A practice update. Paediatr Child Health 2011; 6:459-63. [PMID: 20107554 DOI: 10.1093/pch/6.7.459] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Anxiety and mood disorders are among the most common disorders in children and adolescents. They presage later emotional difficulties and disabilities. An understanding of the disorders' presentation, common contributing factors and methods of intervention will enable paediatricians and family doctors to provide optimal support to these children and their families. The present paper briefly reviews the epidemiology of anxiety and mood disorders in children and adolescents. Phenomenology is referred to according to the major diagnostic categories for anxiety and depression. Contributing factors, including genetic and environmental components and their possible interaction, are discussed. The management of the disorders, including common strategies for encouraging coping responses, stress reduction and medication, is also described.
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Affiliation(s)
- S J Bradley
- The Hospital for Sick Children and University of Toronto, Toronto, Ontario
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12
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Caccia S, Clavenna A, Bonati M. Antipsychotic drug toxicology in children. Expert Opin Drug Metab Toxicol 2011; 7:591-608. [DOI: 10.1517/17425255.2011.562198] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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13
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Nahshoni E, Sclarovsky S, Spitzer S, Zalsman G, Strasberg B, Weizman A. Early repolarization in young children with attention-deficit/hyperactivity disorder versus normal controls: a retrospective preliminary chart review study. J Child Adolesc Psychopharmacol 2009; 19:731-5. [PMID: 20035591 DOI: 10.1089/cap.2009.0034] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE AND BACKGROUND Early repolarization (ER), considered a common and benign electrocardiographic pattern on the surface 12-lead electrocardiogram (ECG), was recently found to be prevalent among patients with idiopathic ventricular fibrillation. It is also highly predominant in physically active young males. Reports on sudden cardiac death (SCD) of children and adolescents treated with psychotropic agents have raised concerns regarding the need for cardiovascular monitoring and risk stratification schedules. The rate of ER pattern has not been estimated in children with attention deficit/hyperactivity disorder (ADHD). Thus, in the present retrospective chart review study, we estimated the rate of ER pattern, as well as RR, QT, and QTc intervals, from ECG tracings of physically healthy children with ADHD versus physically and mentally healthy controls. METHODS The ECG tracings of 50 children (aged 8.7 +/- 1.4 years; 12 girls, 44 boys) diagnosed as suffering from ADHD were compared to 55 physically and mentally healthy controls (aged 8.25 +/- 2.1 years; 20 girls, 35 boys). ER was defined as an elevation of the QRS-ST junction (J point) of at least 0.1 mV from baseline with slurring or notching of the QRS complex, and assessed separately by two senior cardiologists who were blind to all other data relating to the study participants. RESULTS The rate of ER pattern was significantly higher in ADHD children compared to normal controls (32% vs. 13%, respectively, P = 0.012; relative risk [RR] = 1.68, 95% confidence interval [CI] 1.16-2.44), irrespective of stimulant treatment or gender. All other standard ECG measures (heart rate, QT and QTc intervals) were within normal range. CONCLUSION The rate of ER in children with ADHD is significantly higher than in normal controls. Its clinical significance awaits further research.
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Affiliation(s)
- Eitan Nahshoni
- Geha Mental Health Center, Liaison Service, Rabin Medical Centar, Petach Tikva, Israel.
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Hammerness P, Georgiopoulos A, Doyle RL, Utzinger L, Schillinger M, Martelon M, Brodziak K, Biederman J, Wilens TE. An open study of adjunct OROS-methylphenidate in children who are atomoxetine partial responders: II. Tolerability and pharmacokinetics. J Child Adolesc Psychopharmacol 2009; 19:493-9. [PMID: 19877973 PMCID: PMC2861956 DOI: 10.1089/cap.2008.0126] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate the tolerability of adding OROS methylphenidate (MPH) to children who are partial responders to atomoxetine (ATMX) in the treatment of attention-deficit/hyperactivity disorder (ADHD). METHODS This was a two-phase, 7-week, open study in children aged 6-17 years. Phase 1 initiated ATMX for a minimum of 4 weeks. Phase 2 entered partial responders to ATMX and added OROS MPH to their regimen. Safety was assessed using blood pressure and heart rate measurements, electrocardiogram readings, AEs, laboratories, and ATMX levels. RESULTS Fifty subjects who were partial responders to ATMX received the combination therapy, with 41 subjects completing the entire protocol. As reported elsewhere (Wilens et al., 2009 ), OROS MPH added to partial responders of ATMX was accompanied by a 40% reduction in the ADHD rating scale score and improvements in executive functioning. However, the combination of ATMX plus OROS MPH was associated with greater rates of insomnia, irritability, and loss of appetite compared to ATMX alone. A small significant increase in diastolic blood pressure was observed during adjunctive OROS MPH, with no clinically meaningful changes in electrocardiogram (ECG) parameters during the study. ATMX levels and liver function tests did not significantly change during the combination treatment. CONCLUSION Adjunct OROS MPH in ATMX partial responders yielded an additive adverse effect burden in this short-term study. Further controlled research with larger samples of children is warranted.
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Affiliation(s)
- Paul Hammerness
- Pediatric Psychopharmacology Unit, Massachusetts General Hospital, Harvard Medical School , Boston Massachusetts, USA
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Vitiello B. Understanding the Risk of Using Medications for ADHD with Respect to Physical Growth and Cardiovascular Function. Child Adolesc Psychiatr Clin N Am 2008; 17:459-74, xi. [PMID: 18295156 PMCID: PMC2408826 DOI: 10.1016/j.chc.2007.11.010] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The effects of stimulant medications and atomoxetine on physical growth and on cardiovascular function are reviewed in light of the most recent data, with attention to clinical implications and research needs. Although these medications have a favorable benefit/risk profile and do not induce clinically significant changes in growth or cardiovascular function in the majority of cases, careful patient monitoring is needed to identify individuals at risk for negative outcomes. More research is needed to elucidate the mechanism of growth suppression to estimate better the risk for rare but life-threatening events and test the effectiveness of monitoring procedures.
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Affiliation(s)
- Benedetto Vitiello
- National Institute of Mental Health, Room 7147, 6001 Executive Boulevard, Bethesda, MD 20892-9633, telephone: 301-443-4283, fax 301-443-4045,
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Miller A. Social neuroscience of child and adolescent depression. Brain Cogn 2007; 65:47-68. [PMID: 17624647 PMCID: PMC2099694 DOI: 10.1016/j.bandc.2006.02.008] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2004] [Revised: 02/05/2006] [Accepted: 02/05/2006] [Indexed: 11/30/2022]
Abstract
The social neuroscience of child and adolescent depression is inherently multidisciplinary. Depressive disorders beginning early in life can have serious developmental and functional consequences. Psychopathology research has described depression's defining clinical and contextual features, and intervention research has characterized its response to treatment and prevention programs. Neuroendocrine, electrophysiological, and neuroimaging studies have identified core neurobiological aspects of early-onset mood disorders. These areas are reviewed using a developmental social neuroscience perspective for integrating disparate observations. The paper introduces a dynamic adaptive systems framework, and it discusses hedonic capacity, stress sensitivity, ruminative self-focus, and attentional impairments as fundamental components of mood disorders.
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Affiliation(s)
- Anita Miller
- Department of Psychology, Skidmore College, Saratoga Springs, New York, USA.
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Abstract
Attention deficit/hyperactivity disorder (ADHD), characterized by inattention, hyperactivity/impulsivity, or a combination of these, is being increasingly recognized in adults. Adult ADHD prevalence rates range from 1% to 4%. The pathophysiology of adult ADHD is likely multifactorial, including genetic, environmental, and neurobiological influences. Though ADHD diagnostic criteria per the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) were developed based on child samples, the symptoms are believed to be similar in adults, with some developmental differences in symptom presentation. This article identifies common presenting complaints of adults who have ADHD and provides information useful for differential diagnosis of these patients. Specific strategies for pharmacological and nonpharmacological intervention are also presented.
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Affiliation(s)
- Shannon B Moss
- Baylor Family Medicine Residency at Garland, 601 Clara Barton Boulevard, Suite 340, Garland, TX 75042, USA.
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Wigal SB, Wilens TE, Wolraich M, Lerner M. Hematologic and blood biochemistry monitoring during methylphenidate treatment in children with attention-deficit/hyperactivity disorder: 2-year, open-label study results. Pediatrics 2007; 120:e120-8. [PMID: 17548486 DOI: 10.1542/peds.2006-1402] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES Patients receiving methylphenidate for the management of attention-deficit/hyperactivity disorder are recommended to receive periodic hematologic monitoring. The objective of this study was to evaluate the long-term effects of methylphenidate treatment on blood biochemistry and hematologic values. METHODS This study involved a detailed analysis of changes in hematologic and blood biochemistry values over the course of a 2-year study of once-daily OROS methylphenidate in otherwise healthy children aged 6 to 13 years with attention-deficit/hyperactivity disorder. Routine hematologic and blood biochemistry assessments were performed at baseline, at 6 and 12 months during study treatment, and at the end of the study. RESULTS Of the 407 subjects enrolled in the study, 289 completed year 1, and 229 completed 21 of 24 months. No subject was excluded from entry into the study or discontinued from the study because of abnormalities of any of the blood chemistries evaluated. There were no clinically significant changes from baseline in mean values for hematologic or blood biochemistry parameters. For most values, the mean change in value over the course of the study was <5%. CONCLUSIONS These longer-term data suggest that chronic therapy with OROS methylphenidate has no clinically significant impact on laboratory values, challenging the necessity of routine hematologic monitoring in otherwise healthy children with attention-deficit/hyperactivity disorder who are treated with methylphenidate.
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Affiliation(s)
- Sharon B Wigal
- Department of Pediatrics, University of California, Irvine, CA 92612, USA.
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Pliszka S. Practice parameter for the assessment and treatment of children and adolescents with attention-deficit/hyperactivity disorder. J Am Acad Child Adolesc Psychiatry 2007; 46:894-921. [PMID: 17581453 DOI: 10.1097/chi.0b013e318054e724] [Citation(s) in RCA: 1040] [Impact Index Per Article: 61.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
This practice parameter describes the assessment and treatment of children and adolescents with attention-deficit/hyperactivity disorder (ADHD) based on the current scientific evidence and clinical consensus of experts in the field. This parameter discusses the clinical evaluation for ADHD, comorbid conditions associated with ADHD, research on the etiology of the disorder, and psychopharmacological and psychosocial interventions for ADHD.
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Nahshoni E, Spitzer S, Berant M, Shoval G, Zalsman G, Weizman A. QT interval and dispersion in very young children treated with antipsychotic drugs: a retrospective chart review. J Child Adolesc Psychopharmacol 2007; 17:187-94. [PMID: 17489713 DOI: 10.1089/cap.2007.0061] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVES AND BACKGROUND QT dispersion (QTd) is a measure of interlead variations of the surface 12-lead electrocardiogram (ECG). Increased QTd, found in various cardiac diseases, reflects cardiac instability and risk for lethal cardiac arrhythmias. Research suggests a link between psychotropic treatment, ECG abnormalities (QT prolongation), and increased sudden cardiac mortality rates. Reports of sudden death in children treated with psychotropic drugs have raised concerns about cardiovascular monitoring and risk stratification. QTd analysis has not been investigated in very young children treated with antipsychotic drugs. In the present retrospective chart review study, we calculated QT interval, QTd, and their rate-corrected values in very young children treated with antipsychotics. METHODS The charts of 12 children (ages 5.8 +/- 0.98 yr; 4 girls, 8 boys) were examined before initiation of antipsychotic treatment [risperidone (n = 7), clotinapine (n = 1), and propericiazine (n = 4)] and during the maintenance period after achieving a positive clinical response. Three children were concomitantly maintained on methylphenidate. QT interval, QTd, and their rate-corrected values were calculated. RESULTS QT interval, QTd, and their rate-corrected values were all within normal values both before and after successful drug treatment. CONCLUSIONS This preliminary, naturalistic, small-scale study suggests that antipsychotic treatment, with or without methylphenidate, in very young children is not commonly associated with significant alterations of QT interval and dispersion, suggesting the relative safety of these agents in this unique age group.
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Affiliation(s)
- Eitan Nahshoni
- Geha Mental Health Center, Liaison Service, Rabin Medical Center, Petach Tikva, Israel.
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21
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Donner R, Michaels MA, Ambrosini PJ. Cardiovascular effects of mixed amphetamine salts extended release in the treatment of school-aged children with attention-deficit/hyperactivity disorder. Biol Psychiatry 2007; 61:706-12. [PMID: 16899230 DOI: 10.1016/j.biopsych.2006.05.002] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2005] [Revised: 03/31/2006] [Accepted: 05/04/2006] [Indexed: 10/24/2022]
Abstract
BACKGROUND The cardiovascular safety of mixed amphetamine salts extended release (MAS XR) was evaluated in 2968 children 6-12 years of age with attention-deficit/hyperactivity disorder (ADHD). METHODS In this prospective, open-label, noncomparative, community-based study, subjects whose symptoms of ADHD were well controlled with stimulant medication maintained their established treatment regimens for 2 weeks before enrollment into the current study. Subjects' regimens were then converted to an approximately equivalent once-daily dose of MAS XR 10, 20, or 30 mg/d according to a medication-conversion algorithm, which could be adjusted to 40 mg/d for optimal efficacy and tolerability. Systolic blood pressure (SBP), diastolic BP (DBP), and pulse were measured at each study visit. Twelve-lead electrocardiography was performed at screening and at the end of the extension phase or early termination. RESULTS No clinically significant changes in BP or pulse were observed. Although one subject experienced a QT-prolongation interval > 25%, no clinically significant prolongation in the mean QT interval was seen. Approximately 2.5% of subjects demonstrated two consecutive SBP or DBP values > 95th percentile for age, sex, and height, and 3.6% of subjects' pulse increased by > or = 25 to > or = 110 beats per minute. No serious cardiovascular adverse events or deaths occurred. CONCLUSIONS In addition to demonstrated efficacy and safety, the cardiovascular profile of MAS XR showed generally small divergences from age-specific population norms that pose very limited risk in this patient population.
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Affiliation(s)
- Richard Donner
- Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania 19104, USA.
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Elangbam CS, Wehe JG, Barton JC, Krull DL, Nyska A, Crabbs T, Kissling GE. Evaluation of glycosaminoglycans content and 5-hydroxytryptamine 2B receptor in the heart valves of Sprague-Dawley rats with spontaneous mitral valvulopathy – A possible exacerbation by dl-amphetamine sulfate in Fischer 344 rats? ACTA ACUST UNITED AC 2006; 58:89-99. [PMID: 16996724 DOI: 10.1016/j.etp.2006.08.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2006] [Accepted: 08/09/2006] [Indexed: 10/24/2022]
Abstract
Spontaneous valvulopathy has been described as nodular or segmental thickenings composed of fibromyxoid tissue in the subendocardium of various valve-leaflets in aging rats, but its pathogenesis and significance are incompletely understood. In this study, we examined the 5-hydroxytryptamine 2B receptor (5HT2BR) expression and characterization of extracellular matrix (ECM) components, and related these to the presence of valvulopathy in the mitral valve-leaflet (spontaneous mitral valvulopathy, SMV) of Sprague-Dawley (SD) rats. We also examined hearts from Fischer 344 (F344) rats treated with dl-amphetamine sulfate for 103 weeks to further explore the potential for drug-induced exacerbation of SMV. In SD rats, valve-leaflets with SMV exhibited a greater valve thickness, a higher amount of glycosaminoglycans, a lower amount of collagen and increased number of 5HT2BR-positive cells. Our data on morphology and ECM changes showed a striking similarity between SMV in SD rats and anorexigen-associated valvulopathy in humans, and increased 5HT2BR-positive cells in SMV implies that 5HT2BR may play a role in pathogenesis. Further, increased incidence and severity of SMV in F344 rats by treatment with dl-amphetamine suggest that a drug-induced exacerbation of SMV may exist in rats. However, additional research is needed to confirm a role for 5HT2BR in the pathogenesis of SMV in SD rats, and to further characterize the relationship between dl-amphetamine treatment and exacerbation of SMV in F344 rats.
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Weisler RH, Biederman J, Spencer TJ, Wilens TE, Faraone SV, Chrisman AK, Read SC, Tulloch SJ. Mixed amphetamine salts extended-release in the treatment of adult ADHD: a randomized, controlled trial. CNS Spectr 2006; 11:625-39. [PMID: 16871129 DOI: 10.1017/s1092852900013687] [Citation(s) in RCA: 113] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
INTRODUCTION Attention-deficit/hyperactivity disorder (ADHD) is a serious neurobehavioral disorder of childhood onset that often persists into adolescence and adulthood. Functional impairments, underachievement, and difficult interpersonal relationships illustrate the need for effective treatment of ADHD through adulthood. METHOD This prospective, multisite, randomized, double-blind, placebo-controlled, parallel-group, dose-escalation study was conducted to assess the efficacy, safety, and duration of action of mixed amphetamine salts extended-release (MAS XR) in adults with ADHD, combined type. Adults > or =18 years of age were given placebo or MAS XR 20, 40, or 60 mg/day for 4 weeks. The main outcome measures were the ADHD Rating Scale and Conners' Adult ADHD Rating Scale Short Version Self-Report (CAARS-S-S). RESULTS Two hundred fifty-five subjects were randomly assigned to treatment with MAS XR or placebo. MAS XR treatment was associated with statistically and clinically significant ADHD symptom reduction at endpoint; mean ADHD Rating Scale scores were 18.5 for the 20-mg group (P=.001), 18.4 for the 40-mg group (P<.001), and 18.5 for the 60-mg group (P<.001). Adults with severe symptoms (ADHD Rating Scale score >32 at baseline) had significantly greater symptom reduction with the highest MAS XR dose (60 mg/day), however, this dose-response relationship was determined by post-hoc analysis. The mean MAS XR effect size was 0.8. Statistically significant (P<.05) improvements in CAARS-S-S ADHD index scores occurred at 4- and 12-hours postdose for all MAS XR groups, indicating a 12-hour duration of effect. Symptoms improved within the first treatment week. Most adverse events reported were mild or moderate in intensity, and the most commonly reported adverse events were consistent with the known profile of stimulant medications. Vital signs and electrocardiograms showed no clinically significant cardiovascular changes. CONCLUSION These results suggest that MAS XR is safe and effective in adults with ADHD and controlled ADHD symptoms for up to 12 hours.
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Dumortier G, Welniarz B, Sauvebois C, Medjdoub H, Friche H, Siad N, Degrassat K. [Prescription of psychotropic drugs in paediatry: approved indications and therapeutic perspectives]. Encephale 2006; 31:477-89. [PMID: 16389715 DOI: 10.1016/s0013-7006(05)82409-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
In France, psychotropic drugs may be classified in four categories according to their official data. The first category corresponds to psychotropic drugs with an approved indication available in paediatry. Theyare old agents (e.g. haloperidol, amitriptyline, benzodiazepines...) with the exception of methylphenidate (hyperactivity). The second one corresponds to pharmacological agents approved for some indications obtained with adults but not for a1l (i.e. restricted indication: e.g. sertraline approved in paediatry only for OCD but not for depression, risperidone approved only for the treatment of disruptive behaviors in children with subaverage IQs). For the third category, the psychotropic agent is either contraindicated or unadvised under the age of 15 or 18 years, by lack of data (e.g. most of SSRI or atypical antipsychotic drugs). For the last category, official data available in brief summaries offer no information on paediatric use and consequently their administration does not appear possible. Up to now, no approved use has been delivered to injection route (IM or IV) in France, except for an IM formulation of zuclopenthixol. Prescribing psychotropic drug has to respect good practices including close psychological and somatic monitoring that associates the young patient and his relative (psycho-education program). Particular key-points should be taken into consideration (i.e. pharmacokinetic and physiological specificities, risk of false passage under the age of 6 years with capsules or tablets, presence of alcohol in some oral solution or bitter aroma...). Beside these official data, many studies have been published but must be carefully interpreted according to their level of pertinence. Meta-analysis gather all randomised controlled trials published or not, analyse their specific pertinence and thus provide clinically relevant elements. Randomised controlled trials present clinical interest but key-points in study design must be checked (e.g. number of patients, inclusion and exclusion criteria, length of the study and clinical relevance of clinical scales...). Other studies like open trials or clinical cases do not offersufficient guarantees. Some randomised controlled trials of clinical relevance have been carried out in this population with new pharmacological classes (eg SSRI, atypical antipsychotic drugs) and may lead to extended indications in children and adolescents. According to bibliographic and official data, the main criteria in the prescribing choice may take into consideration the following sis stressing a poor benefit/risk ratio. SSRI may offer better prospects but their use has not been approved in this indication, until now. In OCD, sertraline shows great interest to enhance clinical response and represents the molecule of reference. No drug has been approved for mood disorders in children or adolescent, in France, contrary to USA where lithium can be administered over the age of 12 years. In addition, antiepileptic drugs like carbamazepine or divalproate have conducted to clinical improvement in some studies. Benzodiazepines, hydroxyzine and meprobamate use should be strictly restricted in case of anxiety symptoms but are the only agents approved in this indication despise promising results obtained with SSRI. Transitory insomnia may take advantage of alimemazine prescription (approved use over the age of 36 months). Some typical neuroleptics are indicated in tics or in behaviour disorders associated to autism or related syndromes but present clinical limitations and poor tolerability. Promising clinical trials (randomised or not) have been conducted with new atypical antipsychotic drugs like risperidone. In conclusion, present data available for paediatric use of psychotropic agents emphasizes that safety and effectiveness are not always well established in particular for the treatment of chronic disorders (long term tolerability assessment). Moreover, studies should be carried out to specify factors promoting adherence and quality of life for this young population in order to optimise clinical benefit of drug prescription.
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Affiliation(s)
- G Dumortier
- Service Pharmacie, EPS de Ville-Evrard, 202, avenue Jean-Jauèbs, 93332 Neuilly-sur-Marne
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Prince JB. Pharmacotherapy of attention-deficit hyperactivity disorder in children and adolescents: update on new stimulant preparations, atomoxetine, and novel treatments. Child Adolesc Psychiatr Clin N Am 2006; 15:13-50. [PMID: 16321724 DOI: 10.1016/j.chc.2005.08.002] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
This article reviews data on the safety, tolerability, and efficacy of the extended-delivery stimulant preparations and atomoxetine, including nine methylphenidate formulations, five amphetamine formulations, and one norepinephrine reuptake inhibitor, now indicated for treatment of attention-deficit hyperactivity disorder (ADHD). Six of the nine methylphenidate formulations, three of the five compounds, and the norepinephrine reuptake inhibitor are long-acting, potentially once-daily agents. Data on treatment of common adverse events are described, and data on investigational treatments of ADHD are reviewed.
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Affiliation(s)
- Jefferson B Prince
- Department of Child Psychiatry, Massachusetts General Hospital, Harvard Medical School, 6900 Yawkey Building, 15 Parkman Street, Boston, MA 02114, USA.
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Weisler RH, Biederman J, Spencer TJ, Wilens TE. Long-term cardiovascular effects of mixed amphetamine salts extended release in adults with ADHD. CNS Spectr 2005; 10:35-43. [PMID: 16344839 DOI: 10.1017/s109285290000242x] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To assess long-term cardiovascular effects of mixed amphetamine salts extended release (MAS XR) in adults with attention-deficit/hyperactivity disorder (ADHD) combined subtype. METHODS 223 otherwise healthy adults (>or=18 years of age) with ADHD combined subtype were exposed to <or=24 months of MAS XR (20-60 mg/day). Resting sitting diastolic blood pressure (DBP) and systolic blood pressure (SBP) and pulse were measured at baseline and weekly, then monthly during long-term treatment. Twelve-lead electrocardiograms were obtained at screening/baseline, weekly, then at 3- and 6-month intervals up to 24 months. FINDINGS With MAS XR 20-60 mg/day, mean changes in DBP (1.3+/-9.2 mm Hg; P=.042), SBP (2.3+/-12.5 mm Hg; P=.006), and pulse (2.1+/-13.4 bpm; P=.019) were small and not clinically significant. A clinically insignificant increase in QTcB (corrected by Bazett's formula) interval (7.2 msec; P<.001) was observed at 24 months. No subject exhibited QTcB interval >480 msec (QTcF [corrected by Fridericia's formula] >454 msec). Seven subjects discontinued due to a cardiovascular adverse event (hypertension, n=5, palpitation/tachycardia, n=2); none of these events was reported as serious. Few subjects with normal baseline vital signs (using approved parameters at the time of study initiation) exhibited clinically significant abnormalities at end point; several subjects with borderline baseline values exhibited shifts to abnormal values during MAS XR therapy. CONCLUSION Cardiovascular effects of long-term MAS XR (<or=60 mg/day) were minimal in otherwise healthy adults with ADHD. Nevertheless, vital signs should be monitored prior to and during treatment with any stimulant.
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Affiliation(s)
- Richard H Weisler
- Duke University Medical Center, University of North Carilina, Chapel Hill, Raleigh 27609, USA.
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Findling RL, Biederman J, Wilens TE, Spencer TJ, McGough JJ, Lopez FA, Tulloch SJ. Short- and long-term cardiovascular effects of mixed amphetamine salts extended release in children. J Pediatr 2005; 147:348-54. [PMID: 16182674 DOI: 10.1016/j.jpeds.2005.03.014] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2004] [Revised: 01/28/2005] [Accepted: 03/04/2005] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To assess the short- and long-term cardiovascular effects of once-daily treatment with a mixed amphetamine salts extended-release formulation (MAS XR; Adderall XR(R)) in children age 6 to 12 years with attention-deficit/hyperactivity disorder (ADHD). STUDY DESIGN Short-term cardiovascular effects were assessed during a 4-week, double-blind, randomized, placebo-controlled, forced-dose-titration study of once-daily 10, 20, and 30 mg MAS XR (n = 580). Long-term cardiovascular effects were assessed in 568 subjects during a 2-year, open-label extension study of MAS XR (10 to 30 mg/day). Resting sitting blood pressure and pulse were measured at baseline and weekly during the short-term study, then monthly during long-term treatment. RESULTS Changes in blood pressure, pulse, and QT interval corrected by Bazett's formula (QTcB) in children receiving MAS XR were not statistically significantly different than those changes seen in children receiving placebo during short-term treatment. Mean increases in blood pressure after 2 years of MAS XR treatment (systolic, 3.5 mm Hg; diastolic, 2.6 mm Hg) and pulse (3.4 bpm) were clinically insignificant, and there was no apparent dose-response relationship. CONCLUSIONS Cardiovascular effects of short- and long-term MAS XR were minimal during short- and long-term MAS XR treatment at doses of </= 30 mg/day in otherwise healthy children.
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Weisler RH. Safety, efficacy and extended duration of action of mixed amphetamine salts extended-release capsules for the treatment of ADHD. Expert Opin Pharmacother 2005; 6:1003-18. [PMID: 15952928 DOI: 10.1517/14656566.6.6.1003] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Stimulant medications have proven to be effective in reducing the core symptoms of hyperactivity, impulsivity and inattention and are considered the first line of therapy for patients with attention-deficit/hyperactivity disorder (ADHD). Mixed amphetamine salts extended-release capsules (MAS XR; Adderall XR, Shire Pharmaceuticals Group) include immediate-release pellets of mixed amphetamine salts that release the first half of the dose upon ingestion and delayed-release pellets that begin to release active drug approximately 4 h later. The MAS XR capsule contains the same 3:1 ratio of dextroamphetamine to levoamphetamine as do mixed amphetamine salts immediate-release tablets (MAS IR; Adderall), Shire Pharmaceuticals Group), and the bioavailability and pharmacokinetic profiles of MAS XR 20 mg are comparable to those with MAS IR 10 mg b.i.d. MAS XR has a rapid onset of action--within 1.5 h--and provides 12 h coverage. The efficacy, safety and extended duration of action of MAS XR have been established through clinical studies in school-age children, adolescents and adults.
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Affiliation(s)
- Richard H Weisler
- Department of Psychiatry, Duke University Medical Center, 700 Spring Forest Rd. Suite 125, Raleigh, NC 27609, USA.
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Cheng-Shannon J, McGough JJ, Pataki C, McCracken JT. Second-generation antipsychotic medications in children and adolescents. J Child Adolesc Psychopharmacol 2005; 14:372-94. [PMID: 15650494 DOI: 10.1089/cap.2004.14.372] [Citation(s) in RCA: 105] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE We reviewed available pediatric literature on second-generation antipsychotic medications to assess current evidence of efficacy and safety. METHOD An English language MEDLINE search (1974-2003) was conducted using key words-atypical antipsychotics, children and adolescents, toxicity, clozapine, risperidone, olanzapine, quetiapine, ziprasidone, and aripiprazole. Additional efficacy and safety data were obtained from drug manufacturers. RESULTS We identified 176 reports, including 15 double-blind, controlled trials, 58 openlabel studies, 18 retrospective chart reviews, and 85 case series/reports. The majority of these studies (43%) were of risperidone. Evidence suggests that second-generation antipsychotics are efficacious in the treatment of psychosis, bipolar disorders, pervasive developmental disorders, and Tourette's Disorder, and are potentially useful in mental retardation, conduct disorder, and severe attention deficit hyperactivity disorder (ADHD). The most frequently reported side effects included cardiovascular effects, weight gain, sedation, sialorrhea, extrapyramidal signs, and hyperprolactinemia, although the relative frequencies of these untoward effects vary among medications. CONCLUSION Although the evidence base for pediatric use of second-generation antipsychotics is expanding, the majority of available studies are anecdotal, or short-term, openlabel trials. Reports suggest that these compounds are effective for a variety of psychiatric disorders in children and adolescents, but additional double-blind, controlled studies are required to establish definitive efficacy. Although these medications appear to be well tolerated in short-term studies, long-term follow-up investigations and ongoing clinical monitoring are necessary to confirm their safety in this age group.
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Blair J, Scahill L, State M, Martin A. Electrocardiographic changes in children and adolescents treated with ziprasidone: a prospective study. J Am Acad Child Adolesc Psychiatry 2005; 44:73-9. [PMID: 15608546 DOI: 10.1097/01.chi.0000145372.61239.bb] [Citation(s) in RCA: 84] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To assess the electrocardiographic safety profile of low-dose ziprasidone (< or =40 mg/day) among pediatric outpatients treated for up to 6 months. METHOD This was a prospective, open-label trial involving 20 subjects with a mean age of 13.2 +/- 3.0 years. Subjects received a mean ziprasidone dose of 30 +/- 13 mg/day and were followed for 4.6 +/- 2.0 months, receiving a median of nine electrocardiograms each (range 2-11; total, 176). RESULTS There were statistically significant changes from baseline to peak values in heart rate, PR, and QTc intervals, but not in QRS complex width. The mean QTc prolongation was 28 +/- 26 milliseconds and not related to dose (r = 0.16, p = .07). The peak QTc of three subjects reached or exceeded 450 milliseconds; one subject experienced a 114-millisecond prolongation. There was poor agreement (kappa = 0.25) between automated and manual identification of long QTc intervals (> or =440 milliseconds). CONCLUSIONS These preliminary findings, occurring at doses low by current treatment standards, suggest that close electrocardiographic monitoring is warranted when prescribing ziprasidone to children, particularly at higher doses or when combined with other QTc-prolonging agents.
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Affiliation(s)
- Jennifer Blair
- Yale University School of Medicine, New Haven, CT 06520-7900, USA
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Abstract
Although attention deficit hyperactivity disorder (ADHD) has been officially recognized as persisting into adulthood for more than 25 years, only recently has the condition been studied in adults. There is great syndromatic continuity between childhood and adult ADHD, and thus much of the medication management of adults with ADHD can be based on the experience gained from treating children and adolescents. Stimulant medications remain the treatment of choice and are generally as effective in adults as they are in children. Several extended-release delivery systems that improve convenience and compliance have become available. Several second-line medications are also reviewed. The medications must be fine-tuned to the needs of the individual patient in regard to the dose and timing of dose that achieve optimal therapeutic benefit. Medication adjustment must be done by trial and error because no parameter yet identified predicts the molecule or dose that will provide optimal performance.
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Shannon JC, McClellan J. Early onset schizophrenia: diagnostic dilemmas and treatment challenges. ACTA ACUST UNITED AC 2004. [DOI: 10.2217/14750708.1.1.131] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Hazell PL, Stuart JE. A randomized controlled trial of clonidine added to psychostimulant medication for hyperactive and aggressive children. J Am Acad Child Adolesc Psychiatry 2003; 42:886-94. [PMID: 12874489 DOI: 10.1097/01.chi.0000046908.27264.00] [Citation(s) in RCA: 136] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To compare clonidine with placebo added to ongoing psychostimulant therapy for the treatment of attention-deficit/hyperactivity disorder with comorbid oppositional defiant disorder or conduct disorder. METHOD Children 6 to 14 years of age recruited through 2000 to 2001 were randomized to receive clonidine syrup 0.10 to 0.20 mg/day (n = 38) or placebo (n = 29) for 6 weeks. Primary outcome measures were the Conduct and Hyperactive Index subscales of the parent-report Conners Behavior Checklist. Side effects were monitored using physiological measures and the Barkley Side Effect Rating Scale. RESULTS Evaluable patient analysis showed that significantly more clonidine-treated children than controls were responders on the Conduct scale (21 of 37 versus 6 of 29; chi2(1) = 8.75, p <.01) but not the Hyperactive Index (13 of 37 versus 5 of 29). Compared with placebo, clonidine was associated with a greater reduction in systolic blood pressure measured standing and with transient sedation and dizziness. Clonidine-treated individuals had a greater reduction in a number of unwanted effects associated with psychostimulant treatment compared with placebo. CONCLUSIONS The findings support the continued use of clonidine in combination with psychostimulant medication to reduce conduct symptoms associated with attention-deficit/hyperactivity disorder. Treatment is well tolerated and unwanted effects are transient.
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Labellarte MJ, Crosson JE, Riddle MA. The relevance of prolonged QTc measurement to pediatric psychopharmacology. J Am Acad Child Adolesc Psychiatry 2003; 42:642-50. [PMID: 12921471 DOI: 10.1097/01.chi.0000046860.56865.25] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To consider the relevance of prolonged QTc (QT interval corrected for rate) to pediatric psychopharmacology. METHOD The authors reviewed publications on QTc prolongation and publications on sudden death in Medline from 1968 to November 2002. RESULTS The search yielded more than 20,000 publications. Review manuscripts with clinical recommendations outnumber the few pediatric studies of QTc duration during treatment. Most reviews have been published in the past 5 years, during a time when the Food and Drug Administration restricted five psychotropic medications because of QTc prolongation (sertindole: not approved; thioridazine, mesoridazine, and droperidol: black-box warning; and ziprasidone: bolded warning) and nine somatic medications because of QTc prolongation. CONCLUSION Pretreatment screening, careful selection of psychotropic and/or somatic medication combinations, and recognition of QTc prolongation in electrocardiographic tracings during treatment with medications that prolong QTc are important components of clinical practice.
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Affiliation(s)
- Michael J Labellarte
- Division of Child and Adolescent Psychiatry, Department of Psychiatry, Johns Hopkins University School of Medicine, Baltimore, MD 21287-3325, USA.
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Brahm NC, Buswell A, Christensen D, Brown RD. Assessment of QTc prolongation following thioridazine withdrawal in a developmentally disabled population. J Clin Psychopharmacol 2003; 23:314-5. [PMID: 12826995 DOI: 10.1097/00004714-200306000-00014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Shugart MA, Lopez EM. Depression in children and adolescents. When "moodiness" merits special attention. Postgrad Med 2002; 112:53-6, 59-61. [PMID: 12360657 DOI: 10.3810/pgm.2002.09.1300] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Depression does occur in children and adolescents and can result in significant morbidity and mortality. Therefore, identification and treatment of depression are essential. Referral to a mental health clinician, preferably a child and adolescent psychiatrist, is important for suicide evaluation, psychotherapy, and management of complicated medication treatment regimens. The SSRIs are most often used in youngsters because of their favorable side effect profiles and their efficacy as documented in some double-blind, placebo-controlled studies.
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Affiliation(s)
- Margaret A Shugart
- Child and Adolescent Psychiatry Residency Training Program, University of South Carolina School of Medicine, Suite 103, 15 Medical Park, Columbia, SC 29203, USA.
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Abstract
School refusal is differentiated from other attendance problems such as truancy and school withdrawal. It is characterised by the child's emotional upset at the prospect of going to school, parental awareness of and antipathy toward the problem, and an absence of significant antisocial behaviour in the child. The child's emotional upset is frequently associated with an anxiety disorder, but it may also be associated with a mood disorder. School refusal affects approximately 1% of school children across the primary and secondary school levels. Severe and prolonged school refusal jeopardises the young person's social, emotional and academic development, and may be associated with mental health problems in adulthood. A first step in management involves efficient identification and the assessment of contributing and maintaining factors. Clinical outcome studies support the efficacy of cognitive behavioural therapy (CBT). The psychosocial approach encompassed in CBT incorporates anxiety management training with the young person, behaviour management training with parents and consultation with school personnel. Pharmacological treatments are commonly employed although empirical support for their use is limited. Tricyclic antidepressants and selective serotonin (5-hydroxytryptamine; 5-HT) reuptake inhibitors are the more commonly used agents, with the latter having fewer associated adverse effects. It is suggested that the first line of treatment should be CBT, with simultaneous or subsequent pharmacological treatment contingent upon the response to CBT.
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Affiliation(s)
- D Heyne
- Victorian Child Psychiatry Training Department, Faculty of Medicine, Dentistry, & Health Sciences, University of Melbourne, Australia.
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Varley CK. Sudden death related to selected tricyclic antidepressants in children: epidemiology, mechanisms and clinical implications. Paediatr Drugs 2002; 3:613-27. [PMID: 11577926 DOI: 10.2165/00128072-200103080-00006] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
The association between tricyclic antidepressant (TCA) use in children and increased risk of sudden death is unclear, but still possible. There are suitable alternatives to TCAs for all of the indications in which they have shown efficacy. A prudent practice model for the utilisation of TCAs has been developed. This includes initial utilisation of alternative agents, with TCAs as secondary or tertiary choices; informed consent from patient and family, including mention of the possible relationship of TCA with sudden death; vigilance of the emerging literature; and finally, systematic monitoring of patients, including electrocardiograms, drug serum concentrations and vital signs. This protocol needs to be validated with regard to utility and the degree of assistance it provides in the management of children treated with TCAs.
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Affiliation(s)
- C K Varley
- Division of Psychiatry and Behavioral Sciences, University of Washington, Seattle, USA.
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Abstract
OBJECTIVE The primary purpose of this study was to examine the cardiovascular effects of Adderall (ADL) in a clinic-based group of youths with attention-deficit/hyperactivity disorder ranging in age from 4 to 17 years. METHOD One hundred thirty-seven patients were treated with either methylphenidate (MPH) or ADL. Youths prescribed MPH were given medication twice daily, and youths treated with ADL received medication once daily. Patients were evaluated under five conditions: baseline, placebo, 5 mg/dose, 10 mg/dose, or 15 mg/dose. Resting pulse, diastolic blood pressure, and systolic blood pressure were examined after 1 week at each treatment condition. Changes from baseline on these parameters were examined. RESULTS The short-term cardiovascular effects of both ADL and MPH were modest. No patients experienced any clinically significant change in these cardiovascular measures during the course of this brief trial. CONCLUSION Since the short-term cardiovascular effects of ADL appear minimal, specific cardiovascular monitoring during short-term ADL treatment at doses of 15 mg/day or less does not appear to be indicated. In addition, under similar conditions, using similar methods, both medication treatments led to changes in blood pressure and pulse that were clinically insignificant.
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Affiliation(s)
- R L Findling
- Department of Psychiatry and Pediatrics, University Hospitals of Cleveland, Case Western Reserve University, OH 44106-5080, USA
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Pliszka SR, Greenhill LL, Crismon ML, Sedillo A, Carlson C, Conners CK, McCracken JT, Swanson JM, Hughes CW, Llana ME, Lopez M, Toprac MG. The Texas Children's Medication Algorithm Project: Report of the Texas Consensus Conference Panel on Medication Treatment of Childhood Attention-Deficit/Hyperactivity Disorder. Part II: Tactics. Attention-Deficit/Hyperactivity Disorder. J Am Acad Child Adolesc Psychiatry 2000; 39:920-7. [PMID: 10892235 DOI: 10.1097/00004583-200007000-00022] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Expert consensus methodology was used to develop a medication treatment algorithm for attention-deficit/hyperactivity disorder (ADHD). The algorithm broadly outlined the choice of medication for ADHD and some of its most common comorbid conditions. Specific tactical recommendations were developed with regard to medication dosage, assessment of drug response, management of side effects, and long-term medication management. METHOD The consensus conference of academic clinicians and researchers, practicing clinicians, administrators, consumers, and families developed evidence-based tactics for the pharmacotherapy of childhood ADHD and its common comorbid disorders. The panel discussed specifics of treatment of ADHD and its comorbid conditions with stimulants, antidepressants, mood stabilizers, alpha-agonists, and (when appropriate) antipsychotics. RESULTS Specific tactics for the use of each of the above agents are outlined. The tactics are designed to be practical for implementation in the public mental health sector, but they may have utility in many practice settings, including the private practice environment. CONCLUSIONS Tactics for psychopharmacological management of ADHD can be developed with consensus.
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Affiliation(s)
- S R Pliszka
- Department of Psychiatry, University of Texas Health Science Center, San Antonio, USA.
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