Less Is More: Inpatient Management of a Child With Complex Pharmacotherapy

Abstract

COMPLEX INPATIENT PHARMACOTHERAPY VIGNETTE An 11-year-old boy was admitted to an acute inpatient psychiatric setting because of a recent exacerbation of physical aggression, accompanied by long-standing problems with verbal aggression, irritability, dysphoria, and sleep disturbance. His family history was notable for domestic violence, substance abuse by his father, depression in his mother, and divorce. Initial treatment with methylphenidate 10 mg three times daily at 8 years of age improved his ability to focus, but this benefit dissipated during the next year. Two years ago, the methylphenidate was discontinued and Adderall XR was initiated and titrated up to 60 mg/day. Clonidine was subsequently added and titrated up to 0.1 mg four times daily, with an initial improvement in agitation during the day and some improvement in sleep, but these effects seemed to have waned. In light of ongoing irritability and dysphoria, sertraline was added and titrated up to a dose of 150 mg at bedtime. There were some improvements in mood noted, but the patient remained irritable and became somewhat activated. Valproic acid was added and titrated to a blood level of 105 without benefit, so quetiapine was added and titrated to a dose of 100 mg at 8:00 A.M. and 4:00 P.M. and 200 mg at bedtime. At the time of admission, the parents believed that medication was having no demonstrable benefit. On examination, the boy was hyperactive, impulsive, inattentive, and irritable, with no psychotic symptoms. Blood pressure was 90/58, with a pulse of 68. How would you approach this patient pharmacologically?