Multi Drug Use Questioned


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PedMed: Multi-drug use questioned

Published: July 27, 2007 at 8:00 AM

UPI Senior Science Writer
SAN FRANCISCO, July 27 (UPI) -- Be it a sign of a growing dependency on drug treatments or increasing incidence of coexisting pediatric illnesses, the number of children taking multiple medications is rising at rates some deem unhealthy.

The National Center for Health Statistics reports some 3 million tykes and teens under 18 were taking three or more prescription drugs during the study month in 2002.

In some cases, youngsters suffer simultaneous conditions, so-called comorbidities, which call for separate medicines.

For example, studies show up to one in five children newly diagnosed with type 2 diabetes may also have a psychiatric condition, including depression, attention-deficit/hyperactivity disorder, autism, developmental delay, schizophrenia and bipolar disorder.

"There is a high rate of physical problems in people with psychiatric problems," said Ronald Brown, professor of public health, psychology and pediatrics at Temple University Health Sciences Center in Philadelphia. "If you have two diagnosable conditions, you must manage both."

Sometimes, a medicine may cause symptoms that require additional drugs for relief. For example, clonidine, an anti-hypertension remedy, has been used to alleviate insomnia and other sleep disturbances experienced by many children on Ritalin and other ADHD medications.

One consequence may be an increased risk of suffering ill effects.

"The severity of drug interactions varies significantly, and patients taking multiple medications are more likely to experience adverse drug events as a result of a medication interaction," said Lea Eiland, associate clinical professor of pharmacy practice at the Auburn University Harrison School of Pharmacy in Alabama.

Recent research has raised particular concerns about the unknown effects of mixing two or more psychiatric drugs, a practice called pediatric psychotropic polypharmacy, which has been making especially large gains over the past decade.

"This is a critical issue; it's not uncommon to find a child on an antidepressant, a mood stabilizer and a sleep agent all at the same time, but there's no research to see how these drugs interact with each other," said Dr. Joseph Penn, director of child and adolescent forensic psychiatry at Rhode Island Hospital and clinical assistant professor of psychiatry and human behavior at Brown Medical School.

Among studies in his review of 10 years of published data, an examination of records of 223 tots 3 and younger diagnosed with ADHD showed 57 percent were taking psychiatric medicines, with one-third being treated with two or three medications simultaneously.

Monitoring of reactions to the medicines was erratic, with 19 percent of the tykes visiting the doctor twice a year or less or having no follow-up at all.

"I am very concerned," Penn said. "The (Food and Drug Administration) recently questioned whether there is a link between the use of antidepressants in children and suicidal thoughts -- if there's so much concern over the effects of a single drug, how much riskier is it to prescribe multiple drugs?"

The most common combinations commingle stimulants with other mind medicines. There is also widespread "off-label," or unsanctioned, use of the newer atypical antipsychotics like risperidone, a trend backed by meager data on the drugs' safety and effectiveness in young patients, the researchers said.

In a separate study of patients with schizophrenia, Harvard University investigators found those taking a cocktail of two or more drugs suffered more symptoms, needed twice the dose of medication and remained hospitalized for 1.5 times longer than did those receiving a single medicine.

"The empirical use of combinations of antipsychotic agents appears to be increasing with little research support for the relative efficacy, safety or cost-effectiveness of this practice," the authors wrote in Human Psychopharmacology.

Reporting in Quality of Life Research, German investigators noted that missing from most studies are comparisons of the drug treatments to non-drug therapies.

In its policy statement, the American Academy of Child and Adolescent Psychiatry sounded a similarly cautionary note:

"Little data exist to support advantageous efficacy for drug combinations used primarily to treat comorbid conditions," it stated. "The current clinical 'state-of-the-art' supports judicious use of combined medications, keeping such use to clearly justifiable circumstances."

Penn's list of reasons for doctors piling on the medicines included:

-- Children suffering multiple problems, such as ADHD, sexual, physical or emotional abuse, neglect, trauma, post-traumatic stress, learning, depressive and/or bipolar disorder and substance abuse.

-- Young people facing increasingly complex family dynamics and social challenges, from poor parenting and family conflicts to poverty and criminality.

-- Annual expansion of the number, type, dosing strengths and formulations of psychotropic drugs and direct-to-consumer marketing.

-- Pressure from families, school systems and third-party payers on primary-care practitioners and specialists to medicate with, add or change psychotropic medications.

-- Greater willingness of insurers to pay for pills than for talk therapy.

-- Drug side effects that need to be ameliorated by another drug.

-- Physicians applying to children the standard adult approach of combining medications in treatment-resistant cases.

-- Shorter lists of treatment alternatives -- crisis services, hospital plans, post-hospitalization "step-down" programs -- and longer waiting lists for appointments.

Should medication be recommended for their child, Penn urged families to ask the physician:

-- Is this medicine approved by the FDA and, if so, for what conditions?

-- Is it authorized for use by children and adolescents?

-- What are the medicine's short- and long-term risks and benefits?

-- Are there any possible interactions the drug may have with other psychiatric and non-psychiatric medications?

-- How long will my child need to be on the medicine?

-- Are there any side effects that I should be looking for to report to the doctor?


(Note: This column is based on dozens of reports, conferences and more than 200 interviews with specialists in children's health issues. Wasowicz is the author of the new book, "Suffer the Child: How the Healthcare System Is Failing Our Future," published by Capital Books.)


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See this is what terrifies me about all the "lets try this medication to see if it helps". Instead of actually diagnosing and/or alternative therapy. Sometimes the side effects are worse then the actual issues you had to begin with.