Manic Reaction in a Child Induced by Guanfacine-Extended Release

Abstract

[Author Affiliation]Dean Elbe. 1 Division of Child and Adolescent Mental Health, BC Mental Health and Addiction Services, Vancouver, Canada. 2 Department of Pharmacy, Children's and Women's Health Centre of British Columbia, Vancouver, Canada.Carina Perel-Panar. 1 Division of Child and Adolescent Mental Health, BC Mental Health and Addiction Services, Vancouver, Canada. 3 Department of Psychiatry, University of British Columbia, Vancouver, Canada.Leslie Wicholas. 1 Division of Child and Adolescent Mental Health, BC Mental Health and Addiction Services, Vancouver, Canada. 3 Department of Psychiatry, University of British Columbia, Vancouver, Canada.Address correspondence to: Dean Elbe, PharmD, BCPP, Department of Pharmacy, Children's and Women's Health Centre of British Columbia, Mental Health Building, Office P2-229, 4500 Oak Street, Vancouver V6H 3N1, Canada, E-mail: delbe@cw.bc.caTo the Editor:A 6-year-old 25.5 kg Caucasian female was admitted to our inpatient child psychiatry unit for behavioral and emotional dysregulation, chronic sleep difficulties, self-harm, and suicidal ideation. A history of bipolar disorder in her maternal grandfather was identified. Current medications at admission included risperidone 0.25 mg at bedtime and clonidine 0.025 mg at noon and 0.05 mg at bedtime. All potential medical complications were ruled out.Significant inattention and distractibility were noted and guanfacine extended-release (XR) (Intuniv XR® ) was prescribed. Ten days after dose titration started with 1 mg daily and after the first 2 mg dose, she began to display manic symptoms including decreased need for sleep, excessive energy, giddiness, grandiosity, pressured speech, hypersexuality, increased self-harm (hair pulling, head banging, skin picking, and scratching), and aggression toward her younger sibling and unit staff (hitting, kicking, and punching). Guanfacine XR was titrated down and discontinued. Despite sleeping adequately at night, her mood continued to be elevated and aggressive. A diagnosis of bipolar disorder, unspecified, was made. After consideration of several mood-stabilizing medications (i.e., lithium, divalproex, or aripiprazole), the family consented to a trial of lithium.Manic symptoms took 7 weeks to settle. Over the final 2 weeks in hospital, symptoms improved with lithium treatment. With the combination of lithium and clonidine, our patient was better able to regulate and manage her mood and sleep. The patient's discharge medications were lithium 600 mg at bedtime and clonidine 0.05 mg at bedtime. At 3 months postdischarge, the patient's mood remained relatively stable; however, there continued to be sleep difficulties and corresponding periods of mood dysregulation.DiscussionManic reactions have been previously reported in children with guanfacine immediate-release (IR) (Horrigan and Barnhill 1999). To our knowledge, this is the first published report of a manic reaction with guanfacine XR. There was an increase in dysregulation after initiation of guanfacine XR 1 mg, and in retrospect this may have signaled an impending manic switch. …