Sections

Sections Pediatric Obsessive-Compulsive Disorder
Overview
Presentation
DDx
Workup
Treatment
Medication
References

Medication

Medication Summary

Treatment of OCD in adults has demonstrated that medications are effective, and the existing studies of children with obsessive-compulsive disorder (OCD) using medications also tend to suggest some benefit. SSRIs (ie, fluoxetine,^{[50, 51]}fluvoxamine, paroxetine, citalopram, sertraline^[52]) have been demonstrated to be effective treatments for OCD, and they have a lower rate of adverse effects compared with previously used medications.^[42]These SSRIs are considered the first-line medications for treatment of OCD. The adverse effect profile in children for these medicines is similar to that for adults, except that children and adolescents appear to be more prone to agitation if started at usual adult doses.

Clomipramine, the second-line medication, is the most extensively studied medication in the pediatric population. Despite having more efficacy in reducing obsessive-compulsive symptoms in comparison with SSRIs,^[42] clomipramine results in a higher rate and severity of adverse effects in children.^[42]These are the same as those observed in adults (eg, anticholinergic, antihistaminic, alpha blocking).^[42]

No unexpected, long-term, adverse reactions have been observed with clomipramine; however, tachycardia and slightly increased PR-, QRS-, and QT-corrected intervals on electrocardiograms (ECGs) were noted. Given the potential for tricyclic antidepressant-related cardiotoxic effects, pretreatment and periodic ECG and therapeutic drug monitoring is warranted.

With all of these medicines, a large number of persons with OCD do not respond until after 8–12 weeks of treatment (dissimilar to the shorter time noted in the treatment of depression); thus, waiting at least 8 (preferably 10) weeks before changing medicines or dramatically raising dosages is important.

Approximately one third of patients do not respond to a particular SSRI, and the likelihood of responding drops significantly after 3 SSRI trials.

Because properly executed CBT can be a very effective treatment on its own, complex medication strategies are not recommended until the patient has a trial of CBT, along with an SSRI.

Class Summary

SSRIs are considered first-line agents. The tricyclic antidepressant clomipramine is also used, although it is often attended by more uncomfortable adverse effects.^[42]

Fluoxetine (Prozac)

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Fluoxetine is indicated for acute and maintenance treatment of obsessive-compulsive disorder (OCD) in children. It selectively inhibits presynaptic serotonin reuptake with minimal or no effect on the reuptake of norepinephrine or dopamine.

Fluoxetine may cause more gastrointestinal adverse effects than other SSRIs now currently available, which is the reason it is not recommended as a first choice. It may be given as a liquid and a capsule.

The drug may be administered in 1 dose or in divided doses. The presence of food does not appreciably alter levels of the medication. Fluoxetine may take up to 4-6 weeks to achieve steady state levels, as it has the longest half-life (72 h).

Its long half-life is an advantage and a drawback. If fluoxetine works well, an occasional missed dose is not a problem; if problems occur, eliminating all active metabolites takes a long time. The choice depends on adverse effects and drug interactions. Adverse effects of SSRIs seem to be quite idiosyncratic; thus, relatively few reasons exist to prefer one over another at this point if dosing is started at a conservative level and advanced as tolerated.

Fluvoxamine (Luvox CR)

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Fluvoxamine is indicated for OCD in children aged 8-17 years. It enhances serotonin activity due to selective reuptake inhibition at the neuronal membrane. It does not significantly bind to alpha-adrenergic, histamine, or cholinergic receptors and thus has fewer side effects than do tricyclic antidepressants.

Fluvoxamine has been shown to reduce repetitive thoughts, maladaptive behaviors, and aggression and to increase social relatedness and language use.

Sertraline (Zoloft)

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Zoloft selectively inhibits presynaptic serotonin reuptake. It is indicated for OCD in children aged 6-17 years.

Paroxetine (Paxil, Pexeva)

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This would be unlabeled use. Paroxetine is a potent selective inhibitor of neuronal serotonin reuptake and has a weak effect on norepinephrine and dopamine neuronal reuptake. For maintenance dosing, make dosage adjustments to maintain the patient on the lowest effective dosage, and reassess the patient periodically to determine the need for continued treatment.

Citalopram (Celexa)

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This would be unlabeled use. Citalopram enhances serotonin activity by selective reuptake inhibition at the neuronal membrane. SSRIs are the antidepressants of choice because of their minimal anticholinergic effects. All are equally efficacious. The choice depends on adverse effects and drug interactions.

Clomipramine (Anafranil)

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Clomipramine is indicated for OCD in children aged 10-17 years. It is a dibenzazepine compound belonging to the family of tricyclic antidepressants. The drug inhibits the membrane pump mechanism responsible for the uptake of norepinephrine and serotonin in adrenergic and serotonergic neurons.

Clomipramine affects serotonin uptake while it affects norepinephrine uptake when converted into its metabolite, desmethylclomipramine. These actions may be responsible for its antidepressant activity. Clomipramine is overall more effective than SSRIs for children with OCD; however, clomipramine has more adverse effects.

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Author

James Robert Brasic, MD, MPH, MS, MA Assistant Professor, Russell H Morgan Department of Radiology and Radiological Science and Neurology, Division of Nuclear Medicine and Molecular Imaging, Assistant Professor, Department of Neurology, Johns Hopkins University School of Medicine

James Robert Brasic, MD, MPH, MS, MA is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, American Academy of Neurology, International Parkinson and Movement Disorder Society, Society for Neuroscience, Society of Nuclear Medicine and Molecular Imaging

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Johns Hopkins University School of Medicine; New York City Health and Hospitals/Bellevue, New York University Langone Health<br/>Serve(d) as a speaker or a member of a speakers bureau for: Society of Nuclear Medicine and Molecular Imaging, Maryland Regional Council of Child and Adolescent Psychiatry<br/>Received research grant from: National Institutes of Health, Johns Hopkins University School of Medicine, Intellectual & Developmental Disabilities Research Center (U54 HD079123) at the Kennedy Krieger Institute<br/>Received income in an amount equal to or greater than $250 from: Gerson Lehrman Group; Guidepost<br/>Received royalty from Medscape for other.

Coauthor(s)

Ashley B Durbin, BS, BA

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Chief Editor

Caroly Pataki, MD Health Sciences Clinical Professor of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, David Geffen School of Medicine

Caroly Pataki, MD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, New York Academy of Sciences, Physicians for Social Responsibility

Disclosure: Nothing to disclose.

Additional Contributors

Farzaneh Farhadi, MD Postdoctoral Research Fellow, Johns Hopkins Hospital

Disclosure: Nothing to disclose.

Acknowledgements

This research is supported by the Essel Foundation, the Brain and Behavior Research Foundation (NARSAD), the Tourette Syndrome Association Inc, and the National Institutes of Health.

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author W Douglas Tynan, PhD, to the development and writing of the source article.

Sections Pediatric Obsessive-Compulsive Disorder
Overview
Presentation
DDx
Workup
Treatment
Medication
References

Pediatric Obsessive-Compulsive Disorder Medication

Medication Summary

Antidepressants