Transcript Waist circumference ≥ 90% (M & F)

Court Approval of
Psychotropic Medication
Role of the Attorney:
Understanding Psychotropic Medications
Principles and Concerns
Michael Weinraub, M.D.
Office (213) 526-6385
[email protected]
What I Do at Edelman Court
• Referrals from Judges, minor’s attorneys and
others with case questions and concerns
• Identify cases where biological causes and
unmet medical conditions influence behaviors
• Review medications for side effects
• Review treatment programs for progress
• Ensure treating professionals are
communicating on treatment plans and progress
Status of Psychotropic Medications
in the American Marketplace
– Industry research standards
– Prescribing practices
– After market monitoring
– Ongoing studies in children
– Black Box warnings
• Effexorer.com
• Depakoteer.com
Black Box Warning – SSRI’s
Depakote
Black Box Warning
•
Important Safety Information1,2
•
Hepatic failure resulting in fatalities has occurred in patients receiving valproic acid
and its derivatives. Patients should be monitored closely for the appearance of
nonspecific symptoms that may precede hepatotoxicity. Liver function tests should
be performed prior to therapy and at frequent intervals thereafter, especially during
the first 6 months. Valproate should not be administered to patients with hepatic
disease or significant hepatic dysfunction. Children under the age of two years are at
considerably higher risk of fatal hepatotoxicity.
•
Valproate can produce teratogenic effects such as neural tube defects. Accordingly,
the use of Depakote in women of childbearing potential requires that the benefits of
its use be weighed against the risk of injury to the fetus. This is especially important
when the treatment of a spontaneously reversible condition not ordinarily associated
with permanent injury or risk of death (e.g., migraine) is contemplated. An Information
sheet describing the teratogenic potential of valproate is available for patients.
•
Cases of life-threatening pancreatitis have been reported with valproate, either
initially or after several years of use. Some cases were described as hemorrhagic
with a rapid progression from onset to death. Patients should be warned that
symptoms of pancreatitis require prompt medical evaluation. If pancreatitis is
diagnosed, valproate should be discontinued.
Principle One
• No medication will supplant the need of
understanding what is going on in the
mind of the child.
– Behavior management with medication may
bring rapid symptomatic relief.
– Medications may provide initial cost savings.
– Mental health problems persist until
underlying problem is resolved.
Principle Two
• Starting Medication New to the
Marketplace:
– Do not be the first to use a new medication
– Do not wait to be the last to try a new
medication
Principle Three
• Prescribing practices:
– Raise doses slowly
– Add new and/or additional medications slowly
– Educate caregiver to improve monitoring
– Extreme caution with multiple medications of
the same class
– Monitor results with:
• Appropriate labs
• Height, weight, (BMI) and blood pressure
Body Mass Index
• Best way to evaluate obesity
• Correlates with body fat and is relatively
unaffected by height
• BMI =
• BMI =
Wt (kg)/Ht (m) x Ht (m)
[Wt (lbs)/Ht (inches) x Ht (inches)]
x 703
Classification of BMI in Children
•
•
•
•
Underweight – <5th percentile
Normal weight – 5th to <85th percentile
Overweight – > 85th to < 95th percentile
Obese – > 95th percentile
Principle Four
• Ask the child how the medication is
affecting them:
– Soon after starting a new medication or
changing doses of a medication.
– Do they feel the medication is helping them?
– How do they feel?
– How are they eating and sleeping?
Principle Five
• Psychotropic medications are given as an
adjuvant to therapy
– Therapy may need to be:
• Frequent
• Continuous with the same person
• Supported by caregiver participation
Principle Six
• Long Term Care Monitoring:
– Review current diagnosis to see if consistent
with current treatment
– Consider lowering dose if working
– Consider “wash out” if uncertain what
underlying behaviors are being treated
Concerns
• Frequent disruptions in placement and stopping
and starting medications
• Frequent changing medications without past Hx
• Loss of information of response to medications
• Medicating children who move frequently and
who do not have a family and personal medical
history
• Chemical control without therapeutic
improvement
• Medicating preschoolers
• Prescribing Drugs that are Abused
Antipsychotic Medications
Used in Children
• Used for psychotic episodes as well as to
treat aggression, Bi-polar D/O (BPD),
ADHD & …
• BPD is an increasingly controversial
diagnosis
• Evidence atypicals improve children's lives
with BPD is scarce
• Seroquel, Risperdal, Zyprexa, Geodon,
Abilify
Metabolic Syndrome:
Definition in children
•
•
•
•
•
Triglycerides ≥ 110 mg/dl
HDL ≤ 40 mg/dl (M & F)
Waist circumference ≥ 90% (M & F)
Fasting Blood Glucose ≥ 100 mg/dl
Blood Pressure ≥ 90%
•
Cook S., et al. Arch Pediatr Adolesc Med. 2003;157:821-7.
Metabolic syndrome: other
associations
•
•
•
•
Fatty liver disease with steatosis
Insulin Resistance
Type 2 Diabetes
Chronic kidney disease (GFR<60 mL/min,
microalbuminuria
• Polycystic ovary syndrome
• Obstructive sleep apnea
Antidepressant Medications
Used in Children
• Prozac, Zoloft, Paxil, Celexa, Lexapro
• Concern is for weight gain and increased
sucididal ideation.
Stimulant Medication
Used in Children
• Adderall, Ritalin, Dexedrine
• Other class: Strattera
• Look for history of preexisting structural
cardiovascular conditions.
Mood Stabilizers
Used in Children
•
•
•
•
Depakote, Carbatrol, Lamictal, Trileptal
Close monitoring of laboratory results
Monitoring for increased SI
Monitoring girls for PCOS
PMA Process
• Family and Medical History (?)
• Medical Examination – Organic causes (?)
• Therapy – What kind, by who, and how
frequent (?)
• Medication Effects and Side Effects
• Informed Consent – Patient and
Caregivers informed
• Coordinated Care – Is the team talking
with each other (?)