The use of psychotropic medication in the pediatric population has increased over the past three decades. There are real concerns about over-prescribing and potential adverse events from psychotropic medicines in this vulnerable population in the United States.
Children are prescribed psychiatric drugs for a myriad of symptoms, including depression, anxiety, and attention deficit hyperactivity disorder (ADHD). Psychotropic prescriptions are often the first line of treatment among pediatric mental health patients; however, very little consideration is given to identifying children who may have the highest risk of experiencing potential adverse events. Prescribers often start at a low prescription dose, which is increased (titrated) in the hopes of establishing a therapeutic response or to avoid intolerable side effect.
The adverse events from psychotropic drugs can be quite severe and facilitate homicidal or suicidal tendencies, which calls for the need of precision prescribing using pharmacogenomics in pediatric psychiatry. Pharmacogenomics describes the method of testing the patient's genetic predisposition in how they metabolize pharmaceutical drugs.
The testing generates a prediction model that highlights the best therapeutic response while red-flagging potential adverse effects. The genetic test can be utilized to build a psychiatric prescribing protocol among the pediatric population, which removes the guesswork in current practices.
A research team from the University of Cincinnati College of Medicine conducted an evidence-based review on pharmacogenomic testing in children and adolescent psychiatry, which highlights the susceptible groups and gene mutations most likely to generate adverse events. These genetic subgroups have identifiable variations that profoundly impact the metabolic rate in how enzymes eliminate and process pharmaceutical drugs.
There are four common genetic phenotypes, which are described as ultrarapid, extensive, intermediate, and poor. The two most problematic phenotypes include ultrarapid and poor metabolizers, which are seen on the far ends of the spectrum. Identifying these patients before prescribing psychotropic medications can predict adverse events, contraindications, and the potential for successful psychopharmacologic interventions among children. The outcome of precision prescribing through the use of pharmacogenomics is increased quality of life among the family and patient populations while improving clinical outcomes.
Future studies should focus on prospective research analyzing pediatric clinical outcomes with pharmacogenetics testing. Further, rather than looking at one gene set for predicting drug tolerability, investigators could include the effects of several genes, which work in teams, such as pharmacokinetic and pharmacodynamics subgroups.
Additional studies seeking interactions between psychotropic drugs, genes and other medical exposures, such as neurotoxic metals in pharmaceuticals are needed.
The author Dr. Strawn did disclose research support from the NIH and Edgemont, Forest Research Laboratories. Further, Dr. Strawn declared receiving financial assistance from Assurex/Genesight, which is a pharmacogenomics testing company; however, those funds were not directly paid to him. The co-authors of this study did not declare any conflicts of interest. The study points to the need for pharmacogenetics testing among the pediatric population to facilitate precision psychotropic prescription protocols, which will reduce intolerable adverse events while improving clinical outcomes.
More Info: Wehry, A., Ramsey, L., Dulemba, S., Mossman, S., & Strawn, J. (2018). Pharmacogenomic testing in child and adolescent psychiatry: An evidence-based review. Current Problems in Pediatric and Adolescent Health Care. https://doi.org/10.1016/j.cppeds.2017.12.003
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