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PCPs prescribing medication for ADD, depression should 'start low, go slow'

SAN FRANCISCO — When considering medication for children and adolescents with ADHD, depression and anxiety, PCPs should start with a low dose of a long-acting drug, and then gradually increase as needed, according to data presented at the 2016 AAP National Conference & Exhibition.

“I often tell families, ‘We’re going to start so low that you may not even know that it’s working,’” Rebecca Baum, MD, FAAP, a clinical associate professor of pediatrics at Nationwide Children’s Hospital, in Gahanna, Ohio, said. “But that’s OK, because we’re going to increase it, but we want to get to the point where we’re minimizing side effects, and maximizing treatment benefits. So, start low, titrate, usually starting with long-acting medications.”

According to Baum, behavioral issues are a concern in more than 20% of primary care visits. That, combined with a shortage of specialists such as child psychiatrists, developmental-behavioral pediatricians, and child neurologists, means more PCPs are taking on the role of initiating treatment and managing medications for young patients with mental disorders including ADHD, depression, and anxiety.

The three questions to ask in all cases when considering medication for children and adolescents with apparent behavioral issues, Baum said, are:

• Is this the right diagnosis?
• Are these the right medications and the right doses?
• Is this the best treatment?

PCPs should use standard behavioral rating scales, including the presence of DSM-5 criteria and the Vanderbilt Rating Scales, in their assessment, Baum said. Medication should be judged by efficacy, tolerability, the patient’s needs regarding delivery method and duration, and cost.

For ADHD specifically, stimulants have the highest efficacy, compared to non-stimulants. Titration with methylphenidate products should start with 10 mg of extended release medication each morning, gradually increasing the dosage by 5 to 10 mg every 3 to 7 days if limited benefits and adverse effects are seen, according to Baum. The FDA maximum for dosing per day is 60 mg for most extended release products, 72 mg for methylphenidate ER, and 30 mg for dexmethylphenidate ER and methylphenidate patch.

“Because there are so many of these medications, the good news is you don’t have to know all of them, because they’re all pretty similar,” Baum said. “What I would recommend is that you get to know one or two, in the short-acting or long-acting category, and you have a plan for people who can’t swallow pills, and then being familiar with your plan formularies.”

In cases of children and adolescents with depression and anxiety, considerations for prescribing Selective Serotonin Reuptake Inhibitors (SSRIs) should include significant impairment or distress, recurrent or persistent symptoms, and the inability to access psychosocial interventions, Baum said.

In addition, Baum stressed that, just like with stimulants, SSRI doses should “start low, and go slow,” increasing the dosage after 1 to 2 weeks and then monitoring the patient, with the goal of maximal effectiveness after 4 to 6 weeks. Medication should then continue for 6 to 12 months after symptoms resolve, she added. When discontinuing medication, the dosage should be tapered to avoid withdrawal effects.

Among the adverse effects associated with SSRIs among youth is suicidal thinking, which is printed as a boxed warning. According to Baum, despite no evidence of completed suicides as a result of SSRIs, and a very low prevalence of suicidal ideation among those who take them, this warning has been associated with a decrease in their use. Meanwhile, one of the first increases in the rate of suicides occurred after the box warning was introduced, Baum added.

“What I tell families is that this is a potential concern, and I need to hear from you,” Baum said. “If this is something you’re starting to think about, we’ll go from there. The other thing I tell them is that these medications are incredibly helpful, and we don’t want to withhold the use of these medications from someone who we think really needs it, because that [medication] may prevent a suicide.” — by Jason Laday

Reference:

Baum R. Primary care psychopharmacology for common behavioral disorders; AAP National Conference & Exhibition; Oct. 22, 2016, San Francisco.

Disclosure: Baum reports no relevant financial disclosures.