Managing post-summer medication changes.
As the new school year rolls around, parents, physicians, and pharmacists will once again be re-evaluating children’s medication regimens, including any psychotropic medications needed to treat attention deficit-hyperactivity disorder (ADHD), anxiety, or other conditions.
New treatment options for children diagnosed with ADHD, including stimulant and nonstimulant medications and new dosages, now give healthcare providers more choices than ever to tailor therapy to each child’s own unique needs.
While these medications have been found to be highly effective, they are also accompanied by concerns surrounding misuse, overuse, polypharmacy, and side effects.
Many children may not need to take ADHD medications during summer break, or may need a reduced dosage. As many parents are trying to re-establish their children’s medication regimens for the new school year, pharmacists can play a valuable role in collaborating with physicians, counseling parents and children, and alerting families about any possible medication concerns, whether it is with ADHD medications, antipsychotics, or antidepressants.
Psychotropics in Children
The use of psychotropic medications in children has steadily risen over the last two decades. A 2019 retrospective study evaluating psychiatric medication use in military dependents found that between 2003 and 2015, the number of psychiatric medication prescriptions increased by 3% a year, with larger increases seen in older adolescents. Studies also found that use of these types of medications may also be more prevalent in Medicaid patients. According to data from the Center for Health Care Strategies, the use of psychotropic medications among the pediatric Medicaid population increased 28% between 2005 and 2011.
New Options in ADHD Medications
Prescribers have more treatment options than ever that allow development of a treatment plan based on the unique schedule and needs of the child. “Over the past five to six years there have been more products on the market that are both stimulant and nonstimulant, which is nice because it gives you options,” says Vicki Basalyga, PharmD, BCPS, BCPPS, director of an ASHP of clinical specialists and scientists and council secretary of the Commission on Therapeutics at ASHP.
One of the challenges with stimulant medications is improving a student’s focus during the school day without overstimulating and subsequently disrupting their sleep at night. New dosage forms that have differing durations of action allow prescribers and parents to determine exactly how long the medication works.
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“You can tailor these to your particular patient needs,” Basalyga says. “So some people are able to give their kiddo a long-acting version of the drug. They can actually take it to their school nurse and take [the medication] half way through the day and the nurse will keep the medication [at the school]. That way they are able to go to sleep at night.”
Misuse of Medications
While stimulant medications are highly effective, they also carry a potential for abuse. Nonstimulant medications can be another treatment option with less risk of abuse. A 2018 study examining unnecessary exposure to ADHD medication in children and young adults found that between 2000 and 2014 unnecessary exposure increased by 64%. The study, published in Pediatrics, examined unnecessary exposure (unnecessary ingestion, inhalation, and absorption of these medications), and whether the exposure was intentional or unintentional. The data were compiled from reports to poison control centers in the United States, and included data for individuals up to age 19
A 2014 report estimated that more than 100,000 American toddlers 2 or 3 years old were being medicated for ADHD, which is outside the established guidelines for children. Many states are trying to curb abuse of these medications by requiring prior authorization.
Jake Olson, PharmD, president and CEO of Skywalk Pharmacy, a pharmacy with several locations in Wisconsin, served as part of that state’s drug utilization review board that developed a prior authorization policy for antipsychotic drugs for children 6 or younger. “We were seeing a disturbing trend of 4-, 5-, 6-year-old kids getting put on these medications. It was a very high number of foster children,” Olson says.
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The Wisconsin policy requiring prior authorization was implemented in 2012, and later adapted to apply to children 8 years of age or younger. “The policies and things that were put in place then have fairly effectively curbed the use of these types of medications in children,” Olson says. Under the policy, authorization for antipsychotics must include information on diagnosis, the prescriber’s credentials, target symptoms, body mass index data, and whether the patient is in foster care, and must also provide a clinical justification if the prescriber is requesting a nonpreferred antipsychotic medication.
Polypharmacy can also be a concern with antipsychotic drugs in children.
“One of my biggest concerns regarding the use of psychiatric medications in pediatric patients are the drug-drug interactions that can have a negative impact on growth and well-being,” says Alexis E. Horace, PharmD, BCACP, associate professor at the University of Louisiana at Monroe College of Pharmacy.
There are also concerns about the side-effects and adverse events that can occur when therapies are combined. In fact, a “prescribing cascade” can occur when side effects of medications may be misdiagnosed as symptoms of another problem, Horace explains, rather than as the result of the initial medication.
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“For example, one medication may have a side effect of causing high blood pressure,” she says. Instead of changing or tapering that medication, the patient may be prescribed an antihypertensive that comes with its own drug-drug interactions and side effects, she explains.
“I think some parents would greatly appreciate the help through medication therapy management services,” she says. “However, a show of kindness and concern for the well-being of their family unit will go a long way, especially when helping them manage the treatment of complex chronic conditions of their children.”
Stronger psychotropic drugs such as aripiprazole (Abilify), used to treat conditions such as schizophrenia, bipolar disorder or depression, have shown to increase a patient’s weight and possibly create diabetes risks, Olson says. It’s important that pharmacists effectively communicate these risks and monitor the patient’s weight.
Antidepressants including the selective serotonin reuptake inhibitor (SSRI) category can also carry risks of suicide ideation. These risks need to be clearly discussed with parents and children and weighed against the benefits of these medications.
It is important to keep in mind that these drugs may take 6 to 8 weeks before they are effective. If these drugs are discontinued, the dose must be titrated down slowly to minimize adverse effects, Basalyga says.
Pharmacists and Counseling
Experts agree that one of a pharmacist’s critical roles is providing effective medication guidance to parents and patient. Although most of these medications have risk evaluation and mitigation strategy guidelines that may be discussed in the physician’s office, Olson says pharmacists should make sure that the patient understands the material within these guidelines.
“Ask yourself about your counseling techniques and whether you are really covering these areas,” he says. Pharmacists can address lingering questions as well as check in with patients during their first refill.
Pharmacists should also play a role in helping physicians determine the best treatment options for a particular patient. “There are a wide variety of antipsychotics that can be used, and a pharmacist can inform patients and providers on factors such as dosing frequency, side effects, and other aspects to help determine what’s best for that patient,” Basalyga says.