Transcript Appropriate use of ADHD and AAP for Children

ADHD and AAP
Drug Safety Standards
for Medicaid Children
Health and Recovery Services
Administration (HRSA)
Dr. Jeffrey Thompson, Medical Director
Fee-for-Service (FFS)
Pharmacy Program
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Background

Evidence-based medicine WAC 388-501-0165 defines how
to grade and apply evidence to make coverage decisions.

ADHD and AAP drug reviews were performed by evidencebased practice centers OHSU, RAND, and CADIE.

The Mental Health Community experts join with HRSA in
examining the studies and recommending ADHD and AAP
safety edits for Fee-for-Service (FFS) Medicaid Children.

The Mental Health Drugs Work Group (MHDW) reviews
evidence and examines current utilization practices within
the Children’s Medicaid FFS population.

The MHDW partners with community experts and HRSA to
assess evidence and utilization for appropriate use of ADHD
and AAP drugs for children.
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Some key Questions When Making
Coverage and Safety Decisions
What is the quality of the research justifying
the request?
 What is the estimation of harm if the
treatment was to occur?
 What is the equally effective lower cost
alternative?
 Is there a vulnerable population that
perhaps requires higher levels of evidence?


or IRB approval/informed consent?
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Community ADHD Drug Prescribing
Practices for Medicaid FFS Children
Age 17 and under FY2005
Sedatives
60
80
Amphetamine Salts
5, 188
Methylphenidate
7,303
31
137
108
Dextroamphetamine
565
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Community AAP Drug Prescribing
Practices for Medicaid FFS Children
< 3 yrs.
#Clients
Total
1
# ABOVE
RECOMMENDED
DOSE
1
3–5 Yrs.
# clients
CLOZAPINE
Total
129
40
GEODON
ABILIFY
12
12
CLOZAPINE
-0-
-0-
SEROQUEL
GEODON
2
2
ZPREXA
RISPERDAL
99
11
SEROQUEL
11
11
ZPREXA
5
4
ABILIFY
RISPERDAL
1
1
# ABOVE
RECOMMENDED
DOSE
5
Community AAP Drug Prescribing
Practices for Medicaid FFS Children
6 - 12 YRS
#clients
# ABOVE
RECOMMENDED
DOSE
Total
2657
288
ABILIFY
521
57
CLOZAPINE
-0-
-0-
GEODON
79
25
RISPERDAL
1373
38
SEROQUEL
516
132
ZPREXA
168
36
13 - 17 YRS
# clients
# ABOVE
RECOMMENDED
DOSE
Total
3108
90
ABILIFY
734
15
CLOZAPINE
4
-0-
GEODON
214
9
RISPERDAL
1084
15
SEROQUEL
826
43
ZPREXA
246
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Mental Health Drug Work Group Agrees
on Safety Edits for ADHD and AAP

For endorsing and non-endorsing
providers
1.
2.
3.
4.
5.

Age limits
Dose limits
Combination limits
Sedatives
Second Opinion opportunities
For non-endorsing providers
1.
2.
Tried and failed two preferred, or
Some documentation of intolerance to starting with a preferred
drug
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Children’s ADHD Safety Edits
ADHD Medications
Maximum
Dose
Client
Numbers
% of Total User
Population
Methylphenidates
>5 Years of Age
> 120 mg
296
1.8%
3-5 Years of Age
> 30 mg
415
2.6%
47
<1%
< 3 Years of Age
N/A
Amphetamine
>5 Years of Age
> 60 mg
113
1%
3-5 Years of Age
> l5 mg
330
2%
< 3 Years of Age
N/A
30
<1%
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Mental Health Drug Work Group Safety
Recommendation for APP
Drug
Risperidone
Olanzapine
Quetiapine
Ziprasidone
Aripiprazole
Clozapine
FDA
Max
Dosage
16 mg
20 mg
800 mg
160 mg
30 mg
900 mg
State
Hospital
Max
Dosage
16 mg
20 mg
800 mg
160 mg
30 mg
900 mg
Work Group Max Dosage Recommendations
for Children
<3*
Yrs
3-5*
Yrs
6-12*
Yrs
-0-0-0-0-0-0-
2 mg
4 mg
2.5 mg 10 mg
-0- 200 mg
-0- 80 mg
-0- 15 mg
-0-0-
13-17
Yrs
6 mg
20 mg
600 mg
160 mg
30 mg
900 mg
Work Group Max
Dosage
Recommendations for
Adults
9 mg
40 mg
1200 mg
320 mg
60 mg
900 mg
*Under 13 requires HRSA designated expert opinion
* EPA criteria will be developed to facilitate access for emergent use
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Outcomes
What are the Objectives



Improve Mental Health Therapy
Define Mental Health Therapies
Measure Mental Health Therapy by Reviewing:



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


Number of Rx’s
Assessments
Cognitive behavior
Poly-pharmacy
Poly-prescriber’s
Adherence
Coordination of care
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Questions
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