Spotting polypharmacy children and deprescribing psychotropics

Pediatric psychiatrist describes polypharmacy and deprescribing psychotropics in continuing medical education presentation.

Over the past 20 years, the number of psychotropic medications children receive has increased dramatically, with large increases in attention-deficit/hyperactivity disorder (ADHD) medications and antipsychotics.

Psychotropic medications can level the biologic playing field for children by treating established mental health disorders and controlling disabling symptoms such as hyperarousal and impulsivity.

But they do not change a child’s past or provide the child with new coping skills or a sense of safety, according to W. David Lohr, M.D., a child and adolescent psychiatrist at Norton Children’s Behavioral & Mental Health, affiliated with the UofL School of Medicine. Polypharmacy — multiple medications to treat a single condition — is a risk for children, especially those too young to benefit from psychotropics, according to Dr. Lohr.

Dr. Lohr, a professor in the Division of Child & Adolescent Psychiatry & Psychology at the University of Louisville, presented during a recent continuing medical education opportunity, “Updates in Pediatrics: Deprescribing Psychotropic Medications in Youth.”

Finding the right medications and minimum effective dose

Because of the largely unknown long-term risks to the developing brain, clinicians should consider the option of deprescribing psychotropic medication in children, especially in cases of polypharmacy, according to Dr. Lohr.

“It really just means taking a rational, structured approach to looking at each and every medication a child takes — as to the indications, how they’re being used, and what the risk and benefits are — with the goal of getting to the right number of medications and the minimum effective dose,” Dr. Lohr said.

A clinician should consider deprescribing if:

  • There are concerning medication practices.
  • There is less stress in the patient’s life now.
  • The child has improved with therapy.
  • The medications haven’t helped or have made a child feel worse.
  • There are changes in a patient’s health such as pregnancy, drug abuse or illness.

A child with ADHD who has been stable for several years, with good grades and a stable family, is a good candidate for deprescribing, according to Dr. Lohr. A child treated with an antidepressant for over year who is doing well and doesn’t have a lot of psychosocial stress is another.

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Clinicians also should consider the natural course of illness.

“Depression and anxiety don’t last forever,” Dr. Lohr said. “Trauma exposures and trauma-related sequelae can improve when the child is in a safe place.”

Even with stimulants, which have been shown to be effective throughout life by reducing such negative outcomes as arrest, criminal behavior or substance abuse, studies have shown about a third of children don’t worsen when the medication is stopped.

“It’s a philosophy of treatment that every time you have a child in front of you, you look at the medications that they’re receiving, the medication list, and you go through in your mind, a check-and-balance of asking whether they need each and every one. You consider the role of medications in the overall treatment of the child and consider the youth and family preference”

— William D. Lohr, M.D.

Medication review, followed by deprescribing and monitoring

A clinician should undertake a medication review with the patient and family about each medication the young patient is taking: Who prescribed it and why? How long do they need to take it? What are the expected benefits and risks? How does it help? What are the side effects?

Low-dose medications may be unnecessary, while high doses can cause more side effects.

Before deprescribing, a clinician should have a plan for which medication to stop first and should talk to the family about what signs to watch, including such symptoms as mood and behavior issues. The clinician also should have a discussion with the family about keeping the child active with exercise and activities that help them stay healthy.

Medications should be lowered by 50% every month, even with psychostimulants, according to Dr. Lohr.

When deprescribing, it’s important to have a safety plan in place if the patient worsens. The plan should include evaluation of whether more medication is needed or whether the changes are the result of psychosocial events or therapy, according to Dr. Lohr. A clinician also should monitor whether deprescribing results in any negative educational or social effects.

In collaboration with the state of Kentucky, Norton Children’s Hospital and others, the University of Louisville operates Kentucky SafeMed, which encourages safe use of medication with a focus on deprescribing psychotropic medications. Kentucky SafeMed offers the following guidance for families concerned about overmedication of their children:

At the same time as a medication is being tapered, evidence-based therapies should be in place, such as parenting management or anger management for disruptive behavior. In children with autism or developmental disabilities, such therapies might include speech, occupational and physical therapy, or applied behavioral analysis.

“Drug holidays” are a useful way to understand if medications are still needed. Often, these take place over the summer or holidays.

Potential benefits of deprescribing include fewer adverse drug reactions, improved rates of treatment compliance, less cost for the family and fostering the development of coping strategies.

Deprescribing also can relieve common side effects such as weight gain, movement abnormality and sedation. Antipsychotics can change the percentage of total body fat, subcutaneous fat and insulin sensitivity, and use of psychotropic medications is associated with an increased risk for Type 2 diabetes.

Pediatricians have an important role in monitoring children on psychotropic medications and should assess a patient for deprescribing each time they see the child, ideally quarterly, according to Dr. Lohr.

“It’s a philosophy of treatment that every time you have a child in front of you, you look at the medications that they’re receiving, the medication list, and you go through in your mind, a check-and-balance of asking whether they need each and every one,” Dr. Lohr said.

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