- Email: [email protected]
4.2 PRN Medication Use for Agitation in the Emergency Department: Regional Differences Across the United States
SYMPOSIA 4.2 — 5.0
treated by child and adolescent psychiatrists, illustrates the range of medication usage and the varying degree of efficacy of these medications. Further research is needed into the effectiveness of PRN medications, as is professional guidance for choice of medication and dose.
IMD, MAE, PTA http://dx.doi.org/10.1016/j.jaac.2017.07.596
Conclusions: An appreciation of the extant literature about the pharmacokinetics of these drugs might provide meaningful insights into clinical strategies when these medications are prescribed to acutely agitated youths. Clinicians can incorporate information from these scientific data into evidence-based intervention strategies for this vulnerable population.
AGG, APS, ICP http://dx.doi.org/10.1016/j.jaac.2017.07.598
4.2 PRN MEDICATION USE FOR AGITATION IN THE EMERGENCY DEPARTMENT: REGIONAL DIFFERENCES ACROSS THE UNITED STATES
4.4 PRNS IN HOSPITALIZED CHILDREN FROM 2003-2015
Megan Mroczkowski, MD, Columbia University Medical Center, [email protected]
Gabrielle A. Carlson, MD, SUNY at Stony Brook, Gabrielle. [email protected]
Objectives: More than 30 million children present to emergency departments (ED) in the United States annually. It is estimated that 16–20 percent of US children meet at least partial criteria for a psychiatric disorder; furthermore, 3– 4 percent of all ED presentations are for psychiatric or behavioral chief complaints. A common psychiatric chief complaint is agitation or aggression; furthermore, patients frequently become agitated in the ED. There are no published AACAP Practice Parameters for the psychopharmacologic management of agitation. Further work is needed to characterize PRN (as needed) medication practices for pediatricians and child psychiatrists nationwide. Methods: Work is underway in the Emergency Child Psychiatry Committee to create consensus guidelines written by psychiatrists for the management of agitation in the pediatric ED. This preliminary work has illuminated regional differences in the choice of PRN medications for agitated pediatric patients in the ED. Expanding upon this project, a voluntary written survey for pediatricians and child psychiatrists nationwide was distributed to further characterize PRN medication practices. Results: Based on initial survey responses, there was a vast array of prescribing differences in PRN medications across the country. In the Northeast region of the United States, a sample group was given diphenhydramine, lorazepam, and chlorpromazine or haloperidol to treat mild, moderate, and severe agitation, respectively. In the Pacific Northwest, the sample group was not prescribed diphenhydramine to treat agitation, given the potential for a paradoxical effect. In the Mountain states, atypical antipsychotic drugs were prescribed to the sample group before typical antipsychotic drugs. Most child psychiatrists do not use ziprasidone for agitation because of the risk of QT prolongation. Conclusions: Because there currently are no published AACAP Practice Parameters for the psychopharmacological management of agitation, there is a vast array of prescribing differences in PRN medications across the country. This section illuminates these regional differences in prescribing practices. It invites future research into both effectiveness of medications for this indication and measuring the use of the various interventions.
Objectives: Acutely agitated children account for 50 to 75 percent of children’s psychiatric inpatient unit admissions. Treating these children is clearly a goal. Increasingly, regulatory agencies require this be done without using physical or chemical restraint. Neither long-term outcomes nor randomized trials are available to advise with regard to the best interventions when deescalation and comfort measures fail. This presentation examines changes in the frequency and treatment of outbursts using more than three cohorts of psychiatrically hospitalized children from 2003 to 2015. Methods: PRNs (intramuscular, oral, and seclusion), their frequency, type of medication used, and time between PRNs were examined in three cohorts of inpatients aged five to 12 years (mean age 9.3 years, total N ¼ 345), with n ¼ 215 (62 percent) admitted for outbursts. Approximately 45 percent of children did not require PRNs in spite of their outpatient history of outbursts. We summarize the two most recent cohorts from 2009–2010 (cohort 2) and 2014–2015 (cohort 3) (n ¼ 132). Results: Rates of outbursts per day increased in recent years (from 0.04 to 0.12); 78 percent occurred within the first week of hospitalization. For the first intervention, cohort 2 used more intramuscular and oral diphenhydramine (41.6 vs 4.7 %). Cohort 3 used a neuroleptic drug, usually oral risperidone (95.3 vs. 58.3 %) (P < 0.000). Getting a second PRN (70 % of those getting a first PRN) and additional PRNs, the time to second or third PRN did not differ by cohort or type of intervention (mean 4.4 + 6.9 days). A number of admission medications were similar between cohorts (1.8 + 1.25), but compared with cohort 2, cohort 3 was discharged on significantly more medications (2.0 vs. 2.6), represented mostly by a great increase in the use of a agonists (5.7 vs. 44.3 %, P < 0.000). There was a trend toward higher antidepressant (45.3 vs. 61.5 %) and ADHD medication use (73.6 vs. 86.1 %). The rates of neuroleptic drug (57.6 %) and mood stabilizer use (14.4 %) were similar. Conclusions: The completed study will include previously published data. Although not yet formally compared with cohorts 2 and 3, we tentatively conclude that by themselves, oral PRNs are ineffective at changing the course of severe outbursts. Further data are needed to determine whether this is a dose, timing, or pharmacologic limitation. Double-blind, placebo-controlled treatment studies of agitated children are sorely needed.
ADOL, AGG, PPC http://dx.doi.org/10.1016/j.jaac.2017.07.597
4.3 PHARMACOKINETICS OF PRN MEDICATION IN AGITATED YOUTHS Robert L. Findling, MD, MBA, Kennedy Krieger Institute and Johns Hopkins University, [email protected] Objectives: The purpose of this presentation is to provide a review of what is known about the biodisposition of medications that appear to be commonly used in acutely agitated children and teenagers. Another goal of this presentation is to consider the potential clinical relevance of what is known about the pharmacokinetic parameter estimates of these drugs. Methods: Several literature searches were performed. In addition, books, book chapters, and presentations from relevant scientific meetings were examined. Results: The biodisposition of some of the medications that are used on a PRN basis has been described in the pediatric population. Conversely, there is relatively little known about the pharmacokinetics of several agents that are administered to acutely agitated children. For these reasons, extrapolation from adult data is needed to consider the biodisposition of some agents that are used in these vulnerable patients.
JOURNAL OF THE AMERICAN ACADEMY OF CHILD & ADOLESCENT P SYCHIATRY VOLUME 56 NUMBER 10S OCTOBER 2017
AGG, ALC, ATA http://dx.doi.org/10.1016/j.jaac.2017.07.599
SYMPOSIUM 5 RESEARCH SYMPOSIUM: SOCIAL NEUROSCIENCE AND CHILD AND ADOLESCENT PSYCHIATRY RESEARCH PRIORITIES AT THE NATIONAL INSTITUTE OF MENTAL HEALTH Manpreet K. Singh, MD, Stanford University School of Medicine, [email protected] Objectives: The goals of the 2017 research symposium are to highlight funding priorities of the NIMH relevant to the field of child and adolescent psychiatry and to present groundbreaking basic/translational research in the field of social neuroscience.
www.jaacap.org
S307
treated by child and adolescent psychiatrists, illustrates the range of medication usage and the varying degree of efficacy of these medications. Further research is needed into the effectiveness of PRN medications, as is professional guidance for choice of medication and dose.
IMD, MAE, PTA http://dx.doi.org/10.1016/j.jaac.2017.07.596
Conclusions: An appreciation of the extant literature about the pharmacokinetics of these drugs might provide meaningful insights into clinical strategies when these medications are prescribed to acutely agitated youths. Clinicians can incorporate information from these scientific data into evidence-based intervention strategies for this vulnerable population.
AGG, APS, ICP http://dx.doi.org/10.1016/j.jaac.2017.07.598
4.2 PRN MEDICATION USE FOR AGITATION IN THE EMERGENCY DEPARTMENT: REGIONAL DIFFERENCES ACROSS THE UNITED STATES
4.4 PRNS IN HOSPITALIZED CHILDREN FROM 2003-2015
Megan Mroczkowski, MD, Columbia University Medical Center, [email protected]
Gabrielle A. Carlson, MD, SUNY at Stony Brook, Gabrielle. [email protected]
Objectives: More than 30 million children present to emergency departments (ED) in the United States annually. It is estimated that 16–20 percent of US children meet at least partial criteria for a psychiatric disorder; furthermore, 3– 4 percent of all ED presentations are for psychiatric or behavioral chief complaints. A common psychiatric chief complaint is agitation or aggression; furthermore, patients frequently become agitated in the ED. There are no published AACAP Practice Parameters for the psychopharmacologic management of agitation. Further work is needed to characterize PRN (as needed) medication practices for pediatricians and child psychiatrists nationwide. Methods: Work is underway in the Emergency Child Psychiatry Committee to create consensus guidelines written by psychiatrists for the management of agitation in the pediatric ED. This preliminary work has illuminated regional differences in the choice of PRN medications for agitated pediatric patients in the ED. Expanding upon this project, a voluntary written survey for pediatricians and child psychiatrists nationwide was distributed to further characterize PRN medication practices. Results: Based on initial survey responses, there was a vast array of prescribing differences in PRN medications across the country. In the Northeast region of the United States, a sample group was given diphenhydramine, lorazepam, and chlorpromazine or haloperidol to treat mild, moderate, and severe agitation, respectively. In the Pacific Northwest, the sample group was not prescribed diphenhydramine to treat agitation, given the potential for a paradoxical effect. In the Mountain states, atypical antipsychotic drugs were prescribed to the sample group before typical antipsychotic drugs. Most child psychiatrists do not use ziprasidone for agitation because of the risk of QT prolongation. Conclusions: Because there currently are no published AACAP Practice Parameters for the psychopharmacological management of agitation, there is a vast array of prescribing differences in PRN medications across the country. This section illuminates these regional differences in prescribing practices. It invites future research into both effectiveness of medications for this indication and measuring the use of the various interventions.
Objectives: Acutely agitated children account for 50 to 75 percent of children’s psychiatric inpatient unit admissions. Treating these children is clearly a goal. Increasingly, regulatory agencies require this be done without using physical or chemical restraint. Neither long-term outcomes nor randomized trials are available to advise with regard to the best interventions when deescalation and comfort measures fail. This presentation examines changes in the frequency and treatment of outbursts using more than three cohorts of psychiatrically hospitalized children from 2003 to 2015. Methods: PRNs (intramuscular, oral, and seclusion), their frequency, type of medication used, and time between PRNs were examined in three cohorts of inpatients aged five to 12 years (mean age 9.3 years, total N ¼ 345), with n ¼ 215 (62 percent) admitted for outbursts. Approximately 45 percent of children did not require PRNs in spite of their outpatient history of outbursts. We summarize the two most recent cohorts from 2009–2010 (cohort 2) and 2014–2015 (cohort 3) (n ¼ 132). Results: Rates of outbursts per day increased in recent years (from 0.04 to 0.12); 78 percent occurred within the first week of hospitalization. For the first intervention, cohort 2 used more intramuscular and oral diphenhydramine (41.6 vs 4.7 %). Cohort 3 used a neuroleptic drug, usually oral risperidone (95.3 vs. 58.3 %) (P < 0.000). Getting a second PRN (70 % of those getting a first PRN) and additional PRNs, the time to second or third PRN did not differ by cohort or type of intervention (mean 4.4 + 6.9 days). A number of admission medications were similar between cohorts (1.8 + 1.25), but compared with cohort 2, cohort 3 was discharged on significantly more medications (2.0 vs. 2.6), represented mostly by a great increase in the use of a agonists (5.7 vs. 44.3 %, P < 0.000). There was a trend toward higher antidepressant (45.3 vs. 61.5 %) and ADHD medication use (73.6 vs. 86.1 %). The rates of neuroleptic drug (57.6 %) and mood stabilizer use (14.4 %) were similar. Conclusions: The completed study will include previously published data. Although not yet formally compared with cohorts 2 and 3, we tentatively conclude that by themselves, oral PRNs are ineffective at changing the course of severe outbursts. Further data are needed to determine whether this is a dose, timing, or pharmacologic limitation. Double-blind, placebo-controlled treatment studies of agitated children are sorely needed.
ADOL, AGG, PPC http://dx.doi.org/10.1016/j.jaac.2017.07.597
4.3 PHARMACOKINETICS OF PRN MEDICATION IN AGITATED YOUTHS Robert L. Findling, MD, MBA, Kennedy Krieger Institute and Johns Hopkins University, [email protected] Objectives: The purpose of this presentation is to provide a review of what is known about the biodisposition of medications that appear to be commonly used in acutely agitated children and teenagers. Another goal of this presentation is to consider the potential clinical relevance of what is known about the pharmacokinetic parameter estimates of these drugs. Methods: Several literature searches were performed. In addition, books, book chapters, and presentations from relevant scientific meetings were examined. Results: The biodisposition of some of the medications that are used on a PRN basis has been described in the pediatric population. Conversely, there is relatively little known about the pharmacokinetics of several agents that are administered to acutely agitated children. For these reasons, extrapolation from adult data is needed to consider the biodisposition of some agents that are used in these vulnerable patients.
JOURNAL OF THE AMERICAN ACADEMY OF CHILD & ADOLESCENT P SYCHIATRY VOLUME 56 NUMBER 10S OCTOBER 2017
AGG, ALC, ATA http://dx.doi.org/10.1016/j.jaac.2017.07.599
SYMPOSIUM 5 RESEARCH SYMPOSIUM: SOCIAL NEUROSCIENCE AND CHILD AND ADOLESCENT PSYCHIATRY RESEARCH PRIORITIES AT THE NATIONAL INSTITUTE OF MENTAL HEALTH Manpreet K. Singh, MD, Stanford University School of Medicine, [email protected] Objectives: The goals of the 2017 research symposium are to highlight funding priorities of the NIMH relevant to the field of child and adolescent psychiatry and to present groundbreaking basic/translational research in the field of social neuroscience.
www.jaacap.org
S307