EXPERT ANALYSIS FROM THE PSYCHOPHARMACOLOGY UPDATE INSTITUTE
NEW YORK (FRONTLINE MEDICAL NEWS) – Some of the behavioral and psychiatric problems observed in children with autism spectrum disorder (ASD) may improve on atypical antipsychotics, but these drugs do not improve core symptoms and should be used sparingly in this population, according to an expert’s analysis at a psychopharmacology update held by the American Academy of Child and Adolescent Psychiatry.
“Most children with ASD either do not need or will not benefit from available psychotropic medications,” reported Dr. Jeremy M. Veenstra-VanderWeele of the Center for Autism and the Developing Brain, Columbia University, New York.
In a review of the evidence, he suggested that psychopharmacologic treatments for children with ASD, when indicated at all, are only relevant to behavioral issues and psychiatric comorbidities. On an evidence basis, behavioral modification and psychosocial support for the patient and family should come first or at least accompany psychotropic agents.
“These families are desperate and, oftentimes, they cannot get the services that would actually make things better for their child on a behavioral level,” Dr. Veenstra-VanderWeele said. He said that the “pressure to prescribe,” along with a desire to help, drive many clinicians to offer medications, “but we just should be honest and recognize that our evidence does not suggest that we are able to help the majority.”
Most children with ASD do receive one or more prescriptions for psychotropic agents, according to Dr. Veenstra-VanderWeele’s experience. In fact, he reported that he often is asked to consult on a child who has been prescribed two or three medications when it is unclear which, if any, are offering benefit. While he also finds that these agents often are prescribed at low doses, a better approach would be to use an evidence-based therapy at an adequate dose after carefully evaluating the risk-to-benefit ratio.
“I find that a lot of the kids I see in consultation have had, in desperation, more than one medicine started within the time window of response, and that’s really problematic. That is how kids end up on three or four medicines without a clear sense of what led to improvement,” Dr. Veenstra-VanderWeele noted. He suggested that the more appropriate strategy is to attempt to maximize benefit on one therapy, including behavioral therapies, before initiating another.
In his review of psychotropic medicines for ASD comorbidities, he suggested the evidence is “high” that the atypical antipsychotics risperidone and aripiprazole are effective in at least some children for irritability and agitation. He also reported that the evidence of lack of benefit from secretin also should now be labeled as high.
The evidence for benefit from long-acting stimulants for behavioral improvement was labeled as “moderate,” particularly when considered in the context of adverse events. Atomoxetine, a selective norepinephrine reuptake inhibitor also used for attention-deficit/hyperactivity disorder, is another drug placed by Dr. Veenstra-VanderWeele in the category for “moderate” evidence. Two controlled studies have demonstrated activity, but the overall response in each was relatively modest.
In a third group, labeled “insufficient evidence,” he placed both guanfacine, particularly for irritability, and selective serotonin reuptake inhibitors.
Although the strongest evidence for pharmacotherapy to control comorbidities in ASD is related to atypical antipsychotics, he emphasized that these are accompanied with adverse events. Some, such as weight gain, can be difficult to reverse after long-term therapy.
“Particularly in this population, I talk about stopping the medicine at the time that I start the medicine,” Dr. Veenstra-VanderWeele reported. Citing the frequency of rapid weight gain in patients on some atypical antipsychotics, he said that it is important to warn patients that a switch in therapy may be necessary.
“It is often hard to say we are going to switch when everyone feels that the patient is much better. You have to lay it out in advance and write it down, so the family knows what to expect,” Dr. Veenstra-VanderWeele said.
Management of pediatric ASD typically involves multiple coexisting clinical issues. Because “there is always something else going on” in the ASD patient, he emphasized the need for a systematic approach in which medical and behavioral issues and psychiatric comorbidities are addressed in the context of clear goals for each targeted symptom.
Dr. Veenstra-VanderWeele reported financial relationships with Forest Laboratories, Hoffmann-La Roche, Novartis, Seaside Therapeutics, Sunovion Pharmaceuticals, and SynapDx.