Pediatric pharmacotherapy

Pediatric Pharmacotherapy Fellow University of Oklahoma College of Pharmacy Oklahoma City, Oklahoma Chapter 65 Sickle Cell Disease... 

Rational pediatric pharmacotherapy is primarily based on the knowledge about a particular drug, including its... 

A growing number of web sites have been developed for pediatric medication information. Most university teaching hospitals and children s medical centers have web sites that include educational programs. For example, the University of Virginia Children s Medical Center web site offers tutorials for health care providers on attention deficit/hyperactivity disorder and cerebral palsy, as well as the institution s Pediatric Pharmacotherapy newsletter. - In addition, many professional organizations for pediatric health care practitioners have web sites, as well as mailing lists, chat rooms, or electronic bulletin boards. Two other useful resources on the Internet are PEDINFO and Harriet Lane Links, the latter sponsored by The Johns Hopkins University. These two noncommercial web sites provide a large number of links to pediatrics-related sites, as well as some feedback on the quality of information contained on many of the linked sites. Table 3 lists these web sites and several others that may be of interest to pediatric clinical pharmacists. 

Buck, M.L. Pediatric Pharmacotherapy. In Pharmacotherapy Self-Assessment Program, 3rd Ed. Carter, B.L., Ed. American College of Clinical Pharmacy Kansas City, Missouri, 2000 179-202, Module 9. 

Developmental differences, disease presentation, disease progression, and comorbidities also need to be considered when determining pediatric pharmacotherapy. Even when the mechanism of action and PD response surface may be similar between pediatric and adult populations, differences in therapy may be indicated based on disease progression. For example, hypertension rarely presents as primary finding in children but most frequently as secondary to renal disease or other processes, which frequently impact the pharmacologic goals of therapy. HIV infection and AIDS will result in a 50% 2-year mortality in untreated infants yet typically takes 10 years in adults to wear down the immune system to the point at which opportunistic infections and AIDS take hold. Thus, therapeutic targets must account for these differences especially if these therapies will be used for chronic conditions. 

Besides the pharmacokinetic differences previously identified between pediatric and older patients, factors related to drug efficacy and toxicity also should be considered in planning pediatric pharmacotherapy. Unique pathophysiologic changes occur in pediatric patients with some disease states. 

Considering that pharmacotherapy is inferior to select non-pharmacologic treatment modalities in pediatric enuresis, pharmacotherapy will be most valuable in patients who are not candidates for nonpharmacologic therapy due to nonadherence or who do not achieve the desired outcomes on nonpharmacologic therapy alone. 

The aims of this chapter are to (1) describe a contemporary approach to assessment for pharmacotherapy (2) describe clinical principles of pediatric psychopharmacology (3) describe clinical decision making in pediatric psychopharmacology and (4) describe current approaches to the medical monitoring of children treated with psychotropic medications. 

March, J. (1999) Current status of pharmacotherapy for pediatric anxiety disorders. In Beidel, D., ed. Treating Anxiety Disorders in Youth Current Problems and Puture Solutions (ADAA/NIMH) Washington, DC Anxiety Disorders Association of America, pp. 42-62. 

As may be expected, studies of antidepressants in treatment of ADHD have not shown a differential effect in ADHD children with or without conduct disorder, depression, or anxiety (Biederman et ah, 1993b). While DMI-treated ADHD children showed a substantial reduction in depressive symptoms compared with placebo-treated patients (Biederman et ah, 1989), DMI appears not to be as powerful an antidepressant in children as the SSRls. (Bostic et ah, 1999). The safety and efficacy of combined SSRl and stimulant pharmacotherapy has been addressed in two open studies and is currently being evaluated in a prospective study conducted by the Resarch Units in Pediatric Psychopharmacology (RUPP) Network (B. Vitiello, personal communication). 

Biederman, J., Wilens, T., Mick, E., Spencer, T., and Faraone, S.V. (1999b) Pharmacotherapy of attention-deficit/hyperactivity disorder reduces risk for substance use disorder. Pediatrics 104 e20. 

TABLE 43.1 Pediatric Post-traumatic Stress Disorder Pharmacotherapy Studies... 

The TCAs appear to reduce symptoms of reexperiencing and depression related to PTSD. In children and adolescents, imipramine may be an effective agent for ASD symptoms, especially traumatic experiences or flashbacks related to sleep onset and sleep maintenance (Robert et al., 1999). Because of their safety and side effect profile and the apparent lack of effectiveness in childhood depression, the TCAs have been supplanted by the SSRIs as first-line pharmacotherapy in the treatment of depression and anxiety in childhood. As such, these agents should be reserved for second- or third-line treatment in pediatric PTSD. 

The pharmacotherapy of SUD across the life span is an intense area of research, but few studies are being done with pediatric populations, as evidenced by the AACAP Practice Parameters description of the existing research on the pharmacotherapy of adolescent SUD as limited (Bukstein, 1997). As a paucity of pediatric literature exists, clinicians have relied on findings in adults to develop pediatric treatment protocols. However, the generalizability of the diagnostic criteria and treatment data for adult SUD to pediatric populations remains unclear (Bukstein et al., 1989 Bukstein et al., 1992). 

In this chapter, we will provide a systematic review of the available literature on the pharmacotherapy of pediatric addictions, and representative studies will be summarized for each of the aforementioned classes (see Table 45.2). Treatment of nicotine addictions will not be addressed in this chapter. Overall, there is a paucity... 

Vitiello, B. in press Ethical issues in pediatric psychopharmacology research. In Rosenberg, D., Gershon, S., Davanzo P., eds.. Pharmacotherapy for Child and Adolescent Psychiatric Disorders. 

Ronan S, Gold JT Nonoperative management of spasticity in children. Childs Nerv Syst 2007 23 943 [PMID 17646995] Verrotti A et al Pharmacotherapy of spasticity in children with cerebral palsy. Pediatr Neurol 2006 34 1. [PMID 16376270] Ward AB Spasticity treatment with botulinum toxins. J Neural Transm 2008 115 607. [PMID 18389166]... 

Owens JA, Babcock D, Blumer J, Chervin R, Ferber R, Goetting M, Glaze D, Ivanenko A, Mindell J, Rappley M, Rosen C, Sheldon S (2005) The use of pharmacotherapy in the treatment of pediatric insomnia in primary care Rational Approaches. A Consensus Meeting Summary. J Clin Sleep Med 1 49-59... 

Berkowitz RJ, Possidente CJ, McPherson BR, Guillot A, Braun SV, Reese JC. Anaphylactoid reaction to muromo-nab-CD3 in a pediatric renal transplant recipient. Pharmacotherapy 2000 20(l) 100-4. 

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