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Child and adolescent psychopharmacology is a rapidly growing field with psychotropic medications used widely in the treatment of this patient group. However, psychopharmacological treatment guidelines used for adults cannot simply be applied for children or adolescents, thus presenting clinicians and nurse practitioners with assessment and prescribing challenges. Based on the world’s best-selling resource Stahl’s Prescriber’s Guide, this new book provides a user-friendly step-by-step manual on the range of psychotropic drugs prescribed for children and adolescents by clinicians and nurse practitioners.
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Information on this title: www.cambridge.org/9781108446563
© Stephen Stahl 2019
This publication is in copyright. Subject to statutory exception and to the provisions of relevant collective licensing agreements, no reproduction of any part may take place without the written permission of Cambridge University Press.
First published 2019
Printed in the United States of America by Sheridan Books, Inc.
A catalogue record for this publication is available from the British Library.
Library of Congress Cataloging-in-Publication Data
Names: Stahl, Stephen M., 1951– author. | Supplement to (work): Stahl, Stephen M., 1951– Stahl’s essential psychopharmacology : prescriber’s guide. | Supplement to (work): Stahl, Stephen M., 1951– Stahl’s essential psychopharmacology : neuroscientific basis and practical application.
Title: Prescriber’s guide, children and adolescents : Stahl’s essential psychopharmacology / Stephen Stahl ; editorial assistant, Meghan M. Grady; with illustrations by Nancy Muntner.
Other titles: Stahl’s essential psychopharmacology : prescriber’s guide, children and adolescents
Description: Cambridge, United Kingdom ; New York, NY : Cambridge University Press, 2018. | Supplement to Stahl’s essential psychopharmacology : prescriber’s guide / Stephen M. Stahl. | Supplement to Stahl’s essential psychopharmacology : neuroscientific basis and practical application / Stephen M. Stahl. | Includes bibliographical references and indexes.
Identifiers: LCCN 2018021688 | ISBN 9781108446563 (paperback)
Subjects: | MESH: Psychotropic Drugs – pharmacology | Drug Prescriptions | Psychopharmacology – methods | Child | Adolescent | Handbooks
Classification: LCC RM315 | NLM QV 39 | DDC 615.7/88–dc23
LC record available at https://lccn.loc.gov/2018021688
ISBN 978-1-108-44656-3 Paperback
Cambridge University Press has no responsibility for the persistence or accuracy of URLs for external or third-party internet websites referred to in this publication and does not guarantee that any content on such websites is, or will remain, accurate or appropriate.
Every effort has been made in preparing this book to provide accurate and up-to-date information that is in accord with accepted standards and practice at the time of publication. Nevertheless, the authors, editors, and publishers can make no warranties that the information contained herein is totally free from error, not least because clinical standards are constantly changing through research and regulation. The authors, editors, and publishers therefore disclaim all liability for direct or consequential damages resulting from the use of material contained in this book. Readers are strongly advised to pay careful attention to information provided by the manufacturer of any drugs or equipment that they plan to use.
Index by drug name (trade names and generic names)
Commonly Prescribed For (bold for FDA approved)
This Child and Adolescent Prescriber’s Guide is intended to complement both Stahl’s Essential Psychopharmacology: Neuroscientific Basis and Practical Application and Stahl’s Essential Psychopharmacology: The Prescriber’s Guide. Stahl’s Essential Psychopharmacology is a textbook that emphasizes mechanisms of action and how psychotropic drugs work upon receptors and enzymes in the brain, whereas The Prescriber’s Guide provides practical information on how to use more than 140 specific psychotropic drugs in clinical practice.
Use of psychotropic drugs in children and adolescents is ever increasing, but information on how and when these agents are to be used differently in children and adolescents compared to adults can be hard to find. Notably, most psychotropic drugs used in children are not specifically approved by the FDA or other regulatory agencies for how they are used in children, but are mostly prescribed “off label” based upon information from controlled trials in adults, whatever literature may exist in pediatric populations, and clinical experience. The evidence base for use of psychotropic drugs in children and adolescents is surprisingly thin and not readily accessed, so we thought it would be useful for practitioners who see children and adolescents to have available a ready source of what information does exist for the use of psychotropic drugs in children and adolescents. The goal here is to combine in one guide the available regulatory approvals, when they exist for pediatric populations, along with not only the regulatory approvals and lessons learned from use of these same agents in adults, but also the experience base, often unpublished, for the use of psychotropic drugs in children by experts.
We have attempted in this first edition of our Child and Adolescent Prescriber’s Guide to provide readers with relevant prescribing information for only a few dozen of the most essential psychotropic drugs used in children and adolescents. The goal is to bring together the existing literature and evidence base along with the experience base of two child psychiatrists, Dr. Desiree Shapiro and Dr. DeeAnn Wong, who have extensive “hands on” clinical practice experience and have served as consultant child psychiatry reviewers for this new book. It would be impossible to include all available information about any drug in a single work, and no attempt is made here to be comprehensive. The purpose of this Guide is instead to integrate the art of clinical practice with the science of psychopharmacology. That means including only essential facts in order to keep things short. Unfortunately, that also means excluding less-critical facts as well as extraneous information, which may nevertheless be useful to the reader but would make the book too long and dilute the most important information. In deciding what to include and what to omit, we have drawn upon common sense and many years of clinical experience of the author and reviewers. We have also consulted formally and informally with many other experienced clinicians who treat children and adolescents and have analyzed the evidence from controlled clinical trials and regulatory filings with government agencies.
In order to meet the needs of the clinician and to facilitate future updates of this Guide, the opinions of readers are sincerely solicited. Any important omitted materials, errors, suggestions, and requests to include more drugs in future editions are particularly important to us. Unique aspects of this Guide are the tips and the pearls sections, so we also welcome suggestions for any additional clinical tips or pearls for use in future editions. Feedback can be emailed to email@example.com.
All of the selected drugs are presented here in the same design format in order to facilitate rapid access to information. This format has been customized for prescribing in children and adolescents, so the organization of the various sections for each drug here will not correspond directly to the same sections in the adult Guide (for those of you familiar with that publication). Specifically, here each drug is broken down into six sections, each designated by a unique color background:
followed by key references.
Therapeutics covers the brand names in major countries; the class and mechanism of action of each drug; the FDA-approved indications for pediatric use, the off-label pediatric uses for approved indications in adults, other off-label uses, and tests. New subsections are what to tell parents, children, and teachers about the drug’s efficacy.
Safety and tolerability explains notable, life-threatening, or dangerous side effects; specific comments on growth and maturation, weight gain and sedation; advice on what to do about side effects; and what to say to parents and children about side effects. This section also contains warnings and precautions, contraindications, long-term use, whether habit-forming, and what happens in overdose.
Dosing and use gives the usual dosing range, dosage forms, how to dose, options for administration, pharmacokinetics, drug interactions, dosing tips, how to switch, how to stop, and when not to prescribe. In addition, drugs for which switching between medications can be complicated, such as antipsychotics, have a special section called The Art of Switching, which includes clinical pearls and graphical representations to help guide the switching process.
What to expect covers onset of action, duration of action, primary target symptoms, what is considered a positive result, how long to treat, what to do if it stops working, and what to do if it doesn’t work.
Special populations gives specific information about comorbid psychiatric disorders and managing comorbidity, comorbid intellectual/developmental disabilities/brain injury, “highly vulnerable” population/foster children, comorbid medical conditions, renal impairment, hepatic impairment, and cardiac impairment.
The art of psychopharmacology gives the author’s opinions on issues such as the potential advantages and disadvantages of any one drug, clinical pearls to get the best out of a drug, and several special sections unique to the pediatric population, including: not just little adults: developmental aspects of treatment; hold on to your seat: what is different about treating children and adolescents compared to adults; practical notes; potential ethical issues and informed assent; and engaging primary care with mental health professionals.
There is a list of the icons used in this Guide following this Introduction, and at the back of the Guide are several indices. The first is an index by drug name, giving both generic names (uncapitalized) and trade names (capitalized and followed by the generic name in parentheses). The second is an index of common uses for the generic drugs included in the Guide and is organized by disorder/symptom. Agents that are approved by the FDA for a particular use in children or adolescents are shown in bold. The third index is organized by drug class and lists all the agents that fall within each particular class. In addition to these indices there is a list of abbreviations.
Readers are encouraged to consult standard references (1) and comprehensive psychiatry and pharmacology textbooks for more in-depth information. They are also reminded that “The art of psychopharmacology” section is the author’s opinion. It is strongly advised that readers familiarize themselves with the standard use of these drugs before attempting any of the more exotic uses discussed, such as unusual drug combinations and doses. Reading about both drugs before augmenting one with the other is also strongly recommended. Today’s child and adolescent psychopharmacologist should also regularly track blood pressure, weight, and body mass index as indicated for his or her patients. The dutiful clinician will also check out the drug interactions of non-central nervous system (CNS) drugs with those that act in the CNS, including any prescribed by other clinicians. Certain drugs may be for experts only and might include clozapine and pimozide, among others. Off-label uses not approved by the FDA and inadequately studied doses or combinations of drugs may also be for the expert only, who can weigh risks and benefits in the presence of sometimes vague and conflicting evidence. Children or adolescents with two or more psychiatric illnesses, substance abuse, and/or a concomitant medical illness may be suitable patients for the expert only. Use your best judgment as to your level of expertise and realize that we are all learning in this rapidly advancing field. The practice of medicine is often not so much a science as it is an art. It is important to stay within the standards of medical care for the field, and also within your personal comfort zone, while trying to help extremely ill and often difficult patients with medicines that can sometimes transform their lives and relieve their suffering.
Finally, this book is intended to be genuinely helpful for practitioners of psychopharmacology by providing them with the mixture of facts and opinions selected by the author. Ultimately, prescribing choices are the reader’s responsibility. Every effort has been made in preparing this book to provide accurate and up-to-date information in accord with accepted standards and practice at the time of publication. Nevertheless, the psychopharmacology field is evolving rapidly and the author and publisher make no warranties that the information contained herein is totally free from error, not least because clinical standards are constantly changing through research and regulation. Furthermore, the author and publisher disclaim any responsibility for the continued currency of this information and disclaim all liability for any and all damages, including direct or consequential damages, resulting from the use of information contained in this book. Doctors recommending and patients using these drugs are strongly advised to pay careful attention to and consult information provided by the manufacturer.
|Class and mechanism of action||US FDA approved for use|
|What to tell parents about efficacy||What to tell children and adolescents about efficacy|
|What to tell teachers about the medication||Notable side effects|
|Life-threatening or dangerous side effects||What to do about side effects|
|What to tell parents about side effects||What to tell children and adolescents about side effects|
|Warnings and precautions||Contraindications|
|Dosing||Drug interactions that may occur|
|Tips for dosing based on the clinical expertise of the author||The art of switching|
|How to stop||When not to prescribe|
|Onset of action||Primary target symptoms|
|What is considered a positive result?||What if it doesn’t work?|
|Comorbid psychiatric disorders/managing comorbidity||Comorbid intellectual/developmental disabilities/brain injury|
|“Highly vulnerable” population/foster children||Renal impairment|
|Hepatic impairment||Cardiac impairment|
|Pregnancy and breast feeding||Potential advantages|
|Not just little adults||Hold On to your seat|
|Practical notes||Potential ethical issues and informed assent|
|Engaging primary care with mental health professionals||Unusual|
|ADHD||attention deficit hyperactivity disorder||LDL||low-density lipoprotein|
|ANC||absolute neutrophil count||MAO||monoamine oxidase|
|BEN||benign ethnic neutropenia||MAOI||monoamine oxidase inhibitor|
|bid||twice a day||mg||milligram|
|BMI||body mass index||ml||milliliter|
|BP||blood pressure||mmHg||millimeters of mercury|
|CBC||complete blood count||MRI||magnetic resonance imaging|
|CBT||cognitive behavioral therapy||MRSA||methicillin-resistant Staphylococcus aureus|
|CMI||clomipramine||NDRI||norepinephrine dopamine reuptake inhibitor|
|CNS||central nervous system||NET||norepinephrine transporter|
|CRP||C-reactive protein||NNT||number needed to treat|
|CYP450||cytochrome P450||NRI||norepinephrine reuptake inhibitor|
|De-CMI||desmethyl-clomipramine||NSAID||nonsteroidal anti-inflammatory drug|
|DMDD||disruptive mood dysregulation disorder||ODT||oral disintegrating tablet|
|DPNP||diabetic peripheral neuropathic pain||ODV||O-desmethylvenlafaxine|
|DRESS||Drug Reaction with Eosinophilia||PD||panic disorder|
|ECG||electrocardiogram||PMDD||premenstrual dysphoric disorder|
|ECT||electroconvulsive therapy||PMT||Parent Management Training|
|EPS||extrapyramidal side effects||prn||as needed|
|ER||extended-release||PTSD||posttraumatic stress disorder|
|FDA||Food and Drug Administration||REMS||risk evaluation and mitigation strategy|
|GABA||gamma-aminobutyric acid||SIADH||syndrome of inappropriate antidiuretic hormone secretion|
|GAD||generalized anxiety disorder||SNRI||dual serotonin and norepinephrine reuptake inhibitor|
|GFR||glomerular filtration rate||SR||sustained release|
|GI||gastrointestinal||SSRI||selective serotonin reuptake inhibitor|
|HDL||high-density lipoprotein||TCA||tricyclic antidepressant|
|HMG CoA||beta-hydroxy-beta-methylglutaryl coenzyme A||TEAS||treatment-emergent activation syndrome|
|IM||intramuscular||TMS||transcranial magnetic stimulation|
|INR||international normalized ratio||TSH||thyroid-stimulating hormone|
|IR||immediate release||ULN||upper limit normal|
|ITP||interpersonal psychotherapy||WBC||white blood cell count|
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