Patients with abrupt early-onset OCD due to PANS tolerate lower doses of antidepressants and antipsychotics
Thienemann, M & Park, M & Chan, A & Frankovich, J. (2021). Journal of Psychiatric Research. 135. 10.1016/j.jpsychires.2021.01.022.
HIGHLIGHTS:
- More than half of patients with PANS require psychotropic medication.
- Side effects requiring a therapy change are common.
- Drug doses at which side effects occur are usually less than recommended.
- Clinicians should start with lower doses of psychotropics in PANS patients.
To characterize drug tolerability in pediatric patients with an abrupt-onset of obsessive-compulsive disorder (OCD) meeting criteria for pediatric acute-onset neuropsychiatric syndrome (PANS).
We reviewed charts of 188 consecutive patients with PANS seen in the PANS clinic, collecting starting, side effect, and tolerated doses, as well as side effect profile for each antidepressant and antipsychotic trial.
Of 188 included patients: 57% had trials of antidepressants and/or antipsychotics. Patients prescribed psychotropics were older at PANS onset (mean 9.5 vs 7.1 years, p < 0.01) and had had a longer delay before presenting to clinic (median 1.4 vs 0.5 years, p < 0.01). Antidepressant indications (n = 146) were OCD (48%), anxiety (44%), and depression (32%). Antipsychotic indications (n = 119) were aggression (34%), psychotic symptoms (28%), and OCD (24%). Side effects requiring medication change occurred in 54% of patients: in 38% of antidepressant trials and 49% of antipsychotic trials. Antidepressants’ most common side effects were anxiety, agitation, aggression, and akathisia. Antipsychotics’ most common side effects were dystonia, aggression, self-injurious behavior, and movement abnormality. Side effects were common at doses lower than the suggested starting doses for these medications. Patients tolerated antidepressants and antipsychotics when doses were low.
When antidepressants and antipsychotics are prescribed to patients with PANS, intolerable side effects were noted at doses lower than or equal to suggested starting doses. Patients with PANS can benefit from these therapies. However, when treating these patients, clinicians are advised to start with significantly lower doses than they might use in other disorders.