The role of polypharmacy in children with developmental

disability: Art or science

Natalie SiloveCHW

Case Study• Simon 13 year old • Severe Autism, Intellectual disability

Non verbal• Normal perinatal history• Autism and DD diagnosed by 3 years• ABA started 30 hours a week• CAM +++

• First consult at age 8 years old • Severe hyperactivity impulsivity no

concentration• Very obsessive water play, light flicking• Lots of stereotypies• Head banging rocking, • Throwing, biting, hitting• Vision hearing ok• Recurrent episodes of vomiting , ear

infections, bleeding nose, ears, over many years

MEDICATIONS TRIALED:• Fluoxetine ( lovan) caused increased

aggression/agitation/ stopped• Fluvoxamine 25mg mane 50mg nocte – helpful

for 18 m and then esclating aggression)• Methylphenidate/dexamphetamine no

improvement ceased• Introduced Endep ( amitriptyline)helpful, • Carbamazepine ( very helpful) ceased due to

rash after adequate trial• Risperidone initially helpful ceased due

increased appetite and weight aripiprazole started

• Diazepam ceased due to tolerance

Current medications– Rabeprazole (Pariet®) one tablet nocet– Naltrexone (50mg tablet)1/2 tablet BD– Clonidine ( 100ug )1/2 tablet m, lunch and 1

nocte– Aripriprazole(10mg tablet) ½ TDS– Amitriptyline 25mgTDS

NB: medical/psych/communication/sensory/OT/behavioural/parenting/social support/referrals etc

Social History• Simon is the oldest of two children of Australian Couple.

Father in IT and Mother RN• Happy marriage, no primary health or mental health

problems• Mother stopped work to ensure adequate intervention and

support in early years and to maximise ABA, went back to work when Simon at school

• Changed schools four times• Stopped work again when school could not cope with

behaviour – tried home school, with ABA and ADHC support

• Mother became more isolated, put on weight, sleep affected diagnosed with depression , refused medication and respite

• Aggression directed to mum, accepted overnight respite provided for two nights every 3-6 months, but respite would call parents and they would have to pick him because aggression

• Mother hospitalised for depression and suicidal behaviours – emergency services brought in to the home, constant changing of carers , medication crises wrong doses, duplication of doses etc

• Mother came out of hospital, managed for another 2 years, strongly proactive, compliant, trying to work with services, but

• Remained on waiting lists for over 18m, then assessment, then therapist would leave, no services, position empty, then someone employed, then maternity leave, never had one therapist for more than two sessions and had repeated needs assessments and no therapy.

• Therapists did not visit the schools, only the home

• Constant behavioural ‘emergencies’ which resulted in suspensions

• Parents more stressed, other son moved to public school, all his activities stopped due to financial constraints, father depressed, staying at work longer and longer, family socially isolated, and eventually mum took S to police station , caught a plane to the Philippines and refused to come back until he was placed in out of home care.

• S in full time out of home care• Parents moved to a smaller house• Parents have retained guardianship and

visit s regularly• Brother off all SSRI medication despite

having been diagnosed with atypical autism

• Mum back at work• Family just been for the first holiday in 13

years!

Ethical Issues:• ? Medication plugging the hole for

psychosocial services

• ? Medication used as a quick fix because psychosocial intervention takes time

• ? Machine gun or pharmacologically rich approach

• ? Threw baby out with water

• In home vs out of home

PolypharmacyLiterature says polypharmacy leads to: -

Increase in drug interactions

Decrease in adherence

Adverse outcomes for patient

“the use of therapeutic agents represents a trade off between benefits of symptoms relief or disease modification that increase quality of life and the risk of short and long term adverse effects”1

1. Morden and Goodman 2011 Archped

13

SRI

NRI

DRI5HT2C

m-ACh

NOS

CYP 2D6

1A2

CYP 3A4

SSRI

6-40 Stahl S M, Essential Psychopharmacology (2000)

Drug cocktails• Pharmacological rich

• Multireceptor focus

• Individualised medication

• Potential for drug interactions both pharmacodynamic and pharmacokinetic

mechanism

When serotonin receptor blockade added

When noradrenaline blockade is added

Summary of receptors and adverse effects

drug receptor Common adverse and positive effect

amitriptyline 1hypotension

Mu Constipation, thirst, blurred vision

SERT Bleeding, platelet aggregation

NERT ‘pseudoanticholinergic’ dry mouth, constipation, urinary retention

5HT2C Increase satiety, weight gain

5HT Agitation initially, nausea initially,

Hypotension, respiratory effects

H1Weight gain, drowsiness

clonidine 2 3Drowsiness, hypotension

aripiprazole D2 Extrapyramidal effects, hyperprolactinemia

5HT2A Decrease positive symptomology

5HT1A Cortical pyramidal neuron, regulates hormones -post synaptic, decreases dopamine release – presynaptic autoreceptor

D3 ?cognitive effects

naltrexone Mu Decrease pleasure response

Practical approach to Medication Setting the stage: • Understand family context background,

views, prejudices, myths

• Parents need context, information, time, reactions may vary from angry, denial, guilt, pragmatic acceptance, relief

• Family issue, not a patient/client issue

• Medication always one part of a holistic/multidisciplinary plan

Considerations: social• Is there a responsible primary carer

• Mental health issues in parents

• Parental medication history

• Substance abuse

• Divorce

• Extended family /friends views

• Media/internet influence

Medical• Provide rationale ( working diagnosis) and information

• Provide sufficient time for discussion

• Opportunity to review and discuss again

• Respectful of parents decision

• Informed Consent clearly documented

• Start low and go slow

• Clear written schedule

• Available for consultation during trial

• Monitoring benefits and side effects

• Emphasise that medication is not forever

• Discuss how medication would be stopped and what would be the best times to do this

Summary• Multi disciplinary • Multi settings• Consistent team approach. No one discipline

has the magic bullet.• Communication between the team members• Medication and at times Polypharmacy has a

valuable role in complex behavioural disorders• Thorough assessment required• Targeted behaviour monitored closely/constant

review• Family focussed intervention