The Selective Serotonin Reuptake Inhibitors (“SSRIs”) may be helpful for the treatment of OCD and anxiety symptoms in PANDAS/PANS. The SSRIs include fluoxetine, fluvoxamine, sertraline, and paroxetine. Although all have a primary effect on serotonin reuptake, each has additional therapeutic effects which cause a variety of side effects. For example, some SSRIs (such as fluoxetine) can cause significant “activation” and should be avoided in children who are already having insomnia and sleep difficulties.
Clinical experience with PANDAS and PANS patients suggests that using a low dose and slow titration minimizes the risks of activation, agitation, akathisia, and other adverse effects of the drugs. The medications MUST be started at an extremely low dose (e.g., 1/4th or less of that used for a typical child). Upward titrations should be adjusted no faster than 2-week intervals. An adequate trial of an SSRI is 10-12 weeks at maximum dosage.
An electrocardiogram (EKG) should be obtained before and during treatment with antipsychotics to monitor the QTc interval—excessive prolongation (QTc >450 mseconds) is a contraindication to use of antipsychotic medications.
Although most side effects are easily managed, the development of suicidal thoughts and/or actions is a cause for immediate concern. The SSRIs are known to cause suicidality in children (the mechanism is unknown) and because of this, the FDA has issued a “black box” warning for their use in pediatric patients. The risk of suicidal thoughts is low and the risk of suicidal behaviors is lower, but even one child is too many – so caution must be exercised with use of the SSRIs. If suicidal thoughts/behaviors develop, the child must be monitored closely as the SSRI is discontinued (remembering that some of the drugs will require tapering to avoid additional adverse effects). In most patients, the therapeutic benefits outweigh the possible adverse effects. Parents should be aware of reports of suicidal thoughts and behaviors developing during SSRI administration.