Southern Consortium for Children Athens, Hocking, Vinton 317 Board ADAMHS Board of Adams-Lawrence-Scioto Counties Gallia-Jackson-Meigs Board of ADAMHS Washington County MHAR Board C A HILD AND DOLESCENT P SYCHOPHARMACOLOGY M ANUAL Issued: November 2005 Compiled by: Peg Meis, M.Ed., LPCC, Director of Crisis Services Reviewed by: Edward Lynam, M.D. & Linda Adams, R.N., MSN Designed by: Jenny Metts Preface To the User: This manual has been put together for informational purposes only. It is not meant to be used for clinical practice. Each physician will have their own methodology in treating children and adolescents, as many of these drugs have not been fully tested for use with patients under the age of 18. It is strongly advised that when questions arise regarding medication for a specific youth that those questions be referred to the treating physician. • Please be aware and attuned to the possible side effects of any medication, especially at the onset of starting any new medication. • In particular, suicidal ideation with antidepressants, stimulants, and Strattera. • Watch for adverse effects of all stimulants, such as hallucinations and psychosis. It is our hope that this manual will be helpful in the field for therapists, case managers, counselors, court personnel, and child-serving agencies. We encourage you to reproduce this manual as needed and to distribute it to all staff who may benefit from its use. This manual can also be downloaded online by going to www.scchildren.com. Southern Consortium for Children Post Office Box 956 Athens, Ohio 45701 740-593-8293 Phone / 740-592-4170 Fax Contact: Peg Meis [email protected] www.scchildren.com Table of Contents ADHD Treatment Adderal..............................................................................................................1 Adderall XR.......................................................................................................3 Catapres............................................................................................................4 Concerta............................................................................................................6 Cylert.................................................................................................................8 Dexedrine..........................................................................................................10 Dexedrine Spanules..........................................................................................10 Focalin...............................................................................................................12 Focalin XR.........................................................................................................12 Inderal...............................................................................................................14 Metadate ER.....................................................................................................6 Ritalin................................................................................................................16 Strattera............................................................................................................18 Anticonvulsants Keppra...............................................................................................................20 Klonopin............................................................................................................22 Lamictal.............................................................................................................24 Neurontin...........................................................................................................26 Topamax...........................................................................................................28 Trileptal.............................................................................................................31 Zonegran...........................................................................................................34 Antidepressant Anafranil............................................................................................................36 Ativan................................................................................................................40 Buspar...............................................................................................................43 Celexa...............................................................................................................44 Cymbalta...........................................................................................................46 Effexor...............................................................................................................49 Effexor XR.........................................................................................................49 Desyrel..............................................................................................................51 Lexapro.............................................................................................................53 Luvox.................................................................................................................54 Norpramin.........................................................................................................56 Paxil..................................................................................................................58 Paxil CR............................................................................................................58 Prozac...............................................................................................................59 Prozac Weekly..................................................................................................59 Remeron...........................................................................................................61 Remeron Soltabs..............................................................................................61 Sarafem.............................................................................................................59 Serzone.............................................................................................................63 Sinequan...........................................................................................................65 Tofranil..............................................................................................................67 Tofranil-PM........................................................................................................67 Wellbutrin..........................................................................................................69 Wellbutrin SR....................................................................................................69 Wellbutrin XL.....................................................................................................69 Zoloft.................................................................................................................71 Table of Contents (Continued) Antiparkinson Cogentin.....................................................................................................73 Antipsychotic Abilify..........................................................................................................75 Clozaril........................................................................................................77 Geodon.......................................................................................................79 Haldol..........................................................................................................80 Mellaril........................................................................................................82 Orap............................................................................................................84 Risperdal.....................................................................................................86 Seroquel.....................................................................................................88 Thorazine....................................................................................................90 Trilafon........................................................................................................93 Zyprexa.......................................................................................................95 Bipolar Treatment Cibalith-S....................................................................................................102 Depakene...................................................................................................97 Depakote....................................................................................................100 Depakote ER..............................................................................................100 Depakote Sprinkles.....................................................................................100 Eskalith.......................................................................................................102 Eskalith CR.................................................................................................102 Lithium........................................................................................................102 Lithobid.......................................................................................................102 Tegretol.......................................................................................................105 Tegretol CR................................................................................................105 Tegretol XR.................................................................................................105 Glossary...............................................................................................107 References...........................................................................................108 Index.................................................................................................109 ADDERALL Brand Name: Adderall Classification: A single entity amphetamine product combining the neutral sulfate dextroamphetamine and amphetamine. How Supplied: Tablets: 5 mg, 7.5 mg,10 mg, 12.5 mg, 15 mg, 20 mg, 30 mg Mechanism of Action: Amphetamines are non-catecholamine sympathomimetic amines with CNS stimulant activity. Indications and Dosage: Attention Deficit Disorder with Hyperactivity: Adderall is indicated as an integral part of a total treatment program for a stabilizing effect in children with the behavioral syndrome. Not recommended for children under the age of 3. In children from 3-5, start with 2.5 mg daily, daily dose may be raised in increments of 2.5 mg at weekly intervals until optimal response is obtained. In children 6 or older, start with 5 mg and increase with a daily dose of 5 mg weekly. Only in rare occasions would it be necessary to exceed more than 40 mg. First dose in the AM, next one 4-6 hrs. later. Adverse Reactions: Cardiovascular: palpitations, tachycardia, elevation of blood pressure Central Nervous System: over stimulation, restlessness, dizziness, insomnia, exacerbation of motor and phonic tics and Tourette’s syndrome, headache, tremor Gastrointestinal: constipation, diarrhea, anorexia, dryness of mouth Endocrine: impotence, changes in libido Interactions: Acidifying agents lower the absorption of amphetamines, MAO inhibitors slow amphetamine metabolism; this can cause headaches and other more serious results. Long-term effects of amphetamines in children have not been well established. Adderall Tablets are not recommended for use in children under 3 years of age with ADHD. Treatment with amphetamines is usually not indicated when ADHD is associated with acute stress reaction. In psychotic children, administration of amphetamines may exacerbate symptoms of behavior disturbance and thought disorder. High potential for abuse. *It is strongly advised that this medication is not mixed with alcohol, illicit drugs or any medication unless consultation with a physician or a pharmacist occurs. 1 ADDERALL (Continued) Nursing, Case Management, Counseling and Parental Considerations: Amphetamines have a high potential for abuse. Administration of amphetamines for prolonged periods of time may lead to drug dependence and must be avoided. Do not use within 14 days of an MAO inhibitor. Manifestations of acute overdose include: • restlessness • tremors • hyperflexia • panic states Children may be encouraged to learn the purpose, dose and main side effects, as appropriate for age and condition. A responsible adult should supervise use in children. Children believed to be overdosed should receive immediate medical treatment. 2 ADDERALL XR Generic: amphetamine sulfate Classification: Central System Nerve Stimulant How Supplied: Capsules: 5 mg, 10 mg, 15 mg, 20 mg, 25 mg, 30 mg Extended Release Mechanism of Action: Unknown. Probably promotes nerve impulse transmission by releasing stored norepinephrine from nerve terminals in the brain. Main sites of activity appear to be the cerebral cortex and the reticular activating system. Indications and Dosage: Attention Deficit Hyperactivity Disorder: Children ages 3-5: 2.5 mg daily, with dosage increases in 2.5 mg increments weekly, prn. Children 6 and older: 5 mg daily to bid, with dosage increases in 5 mg increments weekly, prn. Give first dose on awakening, additional doses given at intervals of 4-6 hours. Dosage rarely exceeds 40 mg daily. Adverse Reactions: Cardiovascular: tachycardia, palpitations, hypertension, arrhythmias Central Nervous System: restlessness, tremor, hyperactivity, talkativeness, insomnia, irritability, dizziness, headache, chills, nervousness Gastrointestinal: dry mouth, metallic taste, diarrhea, constipation, anorexia Genitourinary: impotence Interactions: drug to drug: Acetazolamide, antacids, sodium bicarbonate drug to food: Caffeine: discourage using together Nursing, Case Management, Counseling and Parental Considerations: Use cautiously with hyper excitable patients and with psychotic personalities or a history of suicidal or homicidal tendencies. Should not be used to combat fatigue. May obtain baseline ECG. Take 6 hours before bedtime to avoid sleep interference. 3 CATAPRES Brand Name: Catapres, Catapres TTS Generic: clonidine hydrochloride Classification: Alpha-adrenergic agonist; antihypertensive How Supplied: Patch, transdermal: 1, 2 and 3 (0.1, 0.2, 0.3 mg/day) to 7 day duration Tablets: 0.1 mg, 0.2 mg, 0.3 mg Mechanism of Action: Stimulate alpha 2 adrenoreceptors in the brain stem, thus activating an inhibitory neuron, resulting in reduced sympathetic outflow, producing a decrease in vasomotor tone and heart rate. Indications and Dosage: Aid in growth hormone deficiency. Heroin withdrawal and smoking cessation. Used for behavioral management in children, it is used in ADHD and is sometimes given with a stimulant. Initial dose 0.1 mg 2x a day (AM and PM), increase 0.1 mg per day at weekly intervals. Therapeutic doses between 0.2-0.6 mg in divided doses. 2/4 mg maximum dose. Adverse Reactions: Cardiovascular: low blood pressure, slow heart rate, rapid heart rate Central Nervous System: drowsiness, headaches, dizziness, fatigue, insomnia, anxiety Metabolic: sodium and water retention Gastrointestinal: constipation, dry mouth, loss of appetite Interactions: Tricyclic antidepressants antagonize low blood pressure effects of Clonidine. Beta blockers may potentiate reduced heart rate in patients receiving Clonidine. Discontinue beta blocker several days before Clonidine is tapered off due to possible rebound low blood pressure. *It is strongly advised that this medication is not mixed with alcohol, illicit drugs or any medication unless consultation with a physician or a pharmacist occurs. 4 CATAPRES (CONTINUED) Nursing, Case Management, Counseling and Parental Considerations: Use with caution in diabetic patients or individuals with a history of depression. The physician should set the range of blood pressure and pulse for safe administration. The therapeutic dose is reached gradually, often over a period of days or weeks. When being discontinued, Clonidine should be decreased gradually from 2-4 days. Once the therapeutic dose is achieved, the physician may choose to have the child use the medication patch. The instructions should be read carefully before placing the patch. A responsible adult should check the patch daily. Watch carefully for skin irritation; if severe, the physician may need to reinstitute dose by tablet. The patch may need to be placed where the child cannot remove it. The medication in the patch may be metabolized at different rates by each child. The physician will need to know how long the medication affects behavior in order to regulate a smooth effect of the medication on behavior. Children may be encouraged to learn the purpose, dose and main side effects, as appropriate for age and condition. A responsible adult should supervise use in children. Parents should monitor blood pressure and pulse, especially in the beginning of therapy. Children believed to be overdosed should receive immediate medical attention. 5 CONCERTA AND METADATE ER Generic: methylphenidate hydrochloride Classification: Central Nervous System Stimulant How Supplied: Capsules XR: 20 mg, Tablets: 2.5mg, 5 mg, 10 mg, 20 mg chewable Tablets ER: 10 mg, 18 mg, 27 mg, 36 mg, 54 mg Tablets SR: 20 mg Mechanism of Action: Unknown. Probably promotes nerve impulse transmission by releasing stored norepinephrine from nerve terminals in the brain. In children with hyperkinesias, Concerta has a paradoxical calming effect. Indications and Dosage: Children age 6 and older: 18 mg once daily in the morning, adjust dosage by 18 mg at weekly intervals; not to exceed 54 mg taken in the morning. Maximum dose is 54 mg. Adverse Reactions: Cardiovascular: palpitations, angina, tachycardia, changes in blood pressure and pulse rate, arrhythmias Central Nervous System: nervousness, insomnia, Tourette syndrome, dizziness, headache, akathisia, dyskinesia, seizures, drowsiness Eyes, Ears, Nose, & Throat: pharyngitis, sinusitis Gastrointestinal: nausea, abdominal pain, anorexia Metabolic: weight loss Respiratory: cough, upper respiratory tract infection. Interactions: Drug-food: Beverages containing caffeine; may increase amphetamine and related amine effects. Avoid using together. Effects on lab test results: May decrease platelet and WBC counts and hemoglobin. Contraindications: Contraindicated in patients with hypersensitivity to drug and in those with glaucoma, motor tics, family history or diagnosis of Tourette syndrome, or history of marked anxiety, tension, or agitation. Concerta is contraindicated in glaucoma and motor tics or those with a family history or diagnosis of Tourette syndrome. Don't use Concerta in patients with preexisting severe GI narrowing--pathologic or iatrogenic--such as small bowel inflammatory disease, short-bowel syndrome caused by adhesions or decreased transit time, past history of peritonitis, cystic fibrosis, chronic intestinal pseudo obstruction, or Meckel's diverticulum. 6