Sara PA & Shari

[Christy]

Sara nad Shari,
I would really apprecaite your insight on a situation we are having with my son and the possiblitty of clonidine being the cause. Anyone else with comments or info please feel free to respond as well. Thanks.

Sara,

In reading your replies to others and myself, I have come to think of you as an excellent source of information about medicines.

I was wondering what your thougts are in our situation, my son recently began taking small doses of clonidine as help for his hyperactivity (.05 mg 3 x/day). It seems to do wonders for that BUT were were beginning to see increased agitation and agression and he's had some pretty severe rages. He also seemed overly tired most of the morning. Talked to psychiatrist, she doesn't think clonidine would cause the agression and agitation. We agreed to give only two doses per day because of the tiredness. She made slight increases in his trileptal (from 600mg/day to 625 mg/day) and serequel(175 mg/day to 200 mg/day). We are not seeing a change in the agression and irritability. I am hoping to get an appointment to see psychiatrist again this week.

I read a small blurb in The Bipolar Child book that says that cloidine may lead to depression but there was not details given and no mention of agitation and agression. Does depreesion manifest itself in violence towards others? He does show some signs of what I would call, lack of joy, he wonders from one thing to another without any real desire to engage.

Just an FYI, the geodon/serequel combo and straterra was what he was on prior to a psychiatric hospital stay due to violence. We pulled the straterra (although the doctoer at psychiatric hospital was reluctant to do it and even tried a different ADHD medication that caused a huge rage episode) and added the trileptal and clonidine. The thought was to phase out geodon (currently at 100 mg/day) but the psychiatrist is moving slowly and I am also wondering if this may be a problem, no problems with it in the past, it just doesn't work as well as it had.

I was wondering if you had any thoughts since you have proven to be have excellent information about medications and their reactions.

THANK YOU! I would really appreciate your input.

Shari,

You mentioned in a post on clonidine that it makes your son agressiove so you use only small amounts for sleep. You are the only person on this site or in my general web search that mentions clonidine linked with agression. I am wondering if your doctor has given you any insight on why this is the case or if you have found any information about clonidine leading to agression.

THANKS for your help!
Christy

 

[smallworld]

I'm not Sara or Shari, but I'll chime in anyway.

Did you read the paragraph about Tenex in The Bipolar Child that follows the Clonidine section (page 119, 3rd edition)?

"Because clonidine can cause mood swings in bipolar children, there is speculation as to whether Tenex does as well, as they are in the same class of drugs. If a child seems unstable or irritable and he or she is taking Tenex, its use should be examined."

Clonidine and Tenex are very closely related. I'd wager the side-effect profiles are very similar.

When my son was on Clonidine just at bedtime to help with sleep, his psychiatrist warned us that it can cause a hung-over feeling that can increase irritiability. That may be what you're seeing.

In your shoes, I'd stick with true mood stabilizers and possibly an add-on of an atypical antipsychotic. There are lots of combos and doses to play with until you get it right. He's still on relatively low doses of both Trileptal and Seroquel. You have room to go up. by the way, Geodon can activate kids and make them manic.

My son's psychiatrist at the day treatment program last winter warned us to just worry about the mood issues and forget about medicating ADHD symptoms because those medications cause problems with mood stability.

 

[Christy]

My son's psychiatrist at the day treatment program last winter warned us to just worry about the mood issues and forget about medicating ADHD symptoms because those medications cause problems with mood stability.

Sounds like good advice! And, good point about the tennex being simailar, didn't think of that.

Thanks Smallworld!!!

 

[Shari]

Hi Christy.

I can't seem to find the posts, but there were others who had similar reactions to Clonodine. Perhaps post a threat with a subject of "clonodine and aggression?" or something to that effect.

My son was originally prescribed the Clonodine 1/4 of a .1mg tablet twice daily for hyperactivity. The first problem we had with it was that we not able to titrate the dose down far enough to not knock him out. I was giving him literally a few crumbs of a pill and he'd fall asleep. The next suggestion was to use it at night and hope he had enough effects of it the net day to calm him some. That's when we noticed he was just plain mean all the time. His babysitter noticed it, too, so we did a little testing of the theory. A few days without Clonodine, and he was "normal" - intermittent bouts of aggression. Add the Clonodine back at night, you had a mean little boy the next day, all day. We did this several times over the course of a month with the same results, so I tossed the Clonodine and told his doctor. She had heard of this.

We tried Tenex recently with the same problem...it just knocked him out. When we were not able to give him a dose that didn't knock him out, we didn't bother trying other dosing times, etc, like we did with the Clonodine, I just trashed it.

We keep Clonodine on hand for sleep to use on the nights that he absolutely can't sleep, but we use it very sparingly, tiny little doses, we don't wake him up, we let him sleep til he gets up on his own, and school is a play-by-ear call after he wakes up. The effect doesn't seem as bad, but he's definitely less patient, even with a tiny dose once in a while.

Hope this helps. There was very definitely a relationship between the two.

 

[pepperidge]

Christy

My son reacted really poorly to Tenex. It made him more irritable, and after about ten days we started seeing really frightening physically violent aggressive actions. The kind where you lock yourself in your bedroom to protect yourself...

We stopped the Tenex and the aggression totally stopped (well, went to a place that seems pretty normal for a kid with difficulties regulating his emotions). However, it didn't happen overnight, took about a week or so to get out of system.

by the way, this was the second time we tried Tenex. The first time he was on it about 5-6 days and we d/c because I thought it was making him more irritable, but there were other things going on so I wasn't sure it was the Tenex.

For what is worth, this is a kid who can't tolerate stims (makes him anxious and tics worse), strattera (made tics appear, zombie), Trilpetal, Lamictal, Topamax (no effect). He definitely needs ADHD medications but can't tolerate any. Only thing we have found that helped is a very small dose of Abilify (helps impulse control), and a small dose of Zoloft (which I was totally reluctant to start) which helps with his not getting fixated on things (like going shopping after the stores have closed) and meltdowns.

Anyway, all this to say that I definitely believe there is potential for the Tenex class to cause paradoxical reactions.

 

[pepperidge]

"Christy,

If I am right in your sig. it says your child is adopted, right? Is there any chance he could have Fetal Alcohol Syndrome, among other things maybe?

I ask because on my youngest. It seems as if they are much more difficult to medicate, something that my psychiatrist has told me and the literature also suggests. I think many of the symptoms of Fetal Alcohol Effects (FAE) may look something like bipolar , and could well be, but then again there are Fetal Alcohol Syndrome (FAS) kids that are not true bipolar and don't react to the typical bipolar drug type combos.

Just a thought.

P.

 

[Christy]

Thanks Shari and Pepperidge for sharing your experiences with clonidine and tenex. I experimented today by halfing each dose and the day went much better, no meltdowns until bedtime (although I didn't push him much today, still walking on eggshells from the raging we experienced this weekend). He seemed much happier overall but was really hyper by bedtime, but that's a trade off I'm willing to make.

Pepperidge,
Birthmom smoked during pregnancy but indicated that she did not drink or do drugs, but there it is a possibility she wasn't truthful. It is something to explore.

I managed to get a psychiatrist appointment tomorrow and that is a small miracle
Thanks again,
Christy

 

[Sara PA]

If you want to read the prescribing information for clonidine, google "Catapres prescribing information". The listed post-marketing side effects include

Central and Peripheral Nervous System/Psychiatric: Delirium; mental depression; visual and auditory hallucinations; localized numbness; vivid dreams or nightmares; restlessness; anxiety; agitation; irritability; other behavioral changes; and drowsiness

Post marketing adverse reactions are those that doctors and others report after the drug is approved for sale. Though the prescribing information says that none of these side effects have occurred in more than 0.5% of the people taking it, keep in mind that it is estimated that at best 1-in-10 adverse reactions are reported. It is widely believed that fewer than 1-in-100 are reported.

Way back in 1997 at the Second International Conference on Bipolar, this was presented

Guanfacine (Tenex) and Juvenile Bipolar Illness

Authors: J.P. Horrigan, M.D. and L.J. Barnhill, M.D.

Guanfacine hydrochloride (Tenex) is an alpha-2 adrenergic agonist which has received recent attention in the field of child and adolescent psychiatry due to its apparent benefits in managing attention-deficit/ hyperactivity disorder (ADHD), tic disorders, and posttraumatic stress disorder. The initial reports noted minimal side effects. This poster details six cases of adverse responses to guanfacine, drawn from an initial clinic sample of 95 outpatient boys and girls aged 8 to 15 years who were seen in a university-based developmental neuropsychiatric clinic. In each case, the patient met formal DSM-IV criteria for ADHD while four out of six also met criteria for Tourette's Disorder. Within 72 hours of initiation of guanfacine therapy, drastic changes in mood and behavior occurred in each of these individuals, culminating in states that resembled hypomania and mania, including elevated mood, poor sleep hygiene, and hypersexuality. The dose of guanfacine ranged from l to 2 mg/day. Later investigation revealed that all of the youngsters had clinical and/or familial risk factors for bipolar disorder. The authors speculate about the possible mechanisms behind these side effects, and suggest that bipolar disorder may be a relative contraindication to guanfacine therapy.

For a while that information was included on the Tenex prescribing information. Unfortunately I haven't been able to find the prescribing information for either Tenex or any of the generics for a number of years.

To the best of my knowledge about antihypertensives, pretty much all of them can cause depression. Every one I ever check did but there are a lot of antihypertensives out there, I could be overstating the situation.

The Trileptal is still quite a low dose and may not be particularly effective.

 

[Christy]

Thanks Sara! I will remember to google for post-marketing side effects when considering a medication for difficult child. Most of the time, if it ocurs in a very small percentage of patients, he's one of them!

Appreciate the info,
Christy

 

[Shari]

yw, Christy. Thanks for asking. It makes it a little more tolerable for me to know that occassionally something I learned can be passed on to someone else and possibly help them out. Then I can feel this whole journey isn't for naught.

Glad to help. Good luck today.

 

[gcvmom]

FWIW, my difficult child 2 (the one with mood issues) became manic on Tenex. No irritablity though, but extremely agitated, very pressured speech, racing thoughts, and paranoia.

Hope things go well for you today -- some days it feels like a rollercoaster, doesn't it?

 

[tessaturtle]

My input: our difficult child experienced a significant increase in aggression on seroquel. We would report this aggression to his prescriber and his therapist. In response, his prescriber INCREASED his seroquel. we continued to complain and told him our thoughts - that it was the seroquel that was causing it (it got worse under each increase). He was up to 600 mg with the ARNP suggesting we go up to 800! well, long story short, he ended up in the psychiatric hospital. We told them straight off the bat our thoughts about the seroquel. We thought they listened, but a couple of weeks later, they were telling us that they were having some success with increasing his carbamazapine levels (tegretol) but were still seeing high irritibility and aggression. We asked what other medications they had him on and they said they still had him on SEROQUEL! we explained our thoughts, they weaned him off the seroquel, and wouldn't you know, the aggression and irritibilty significantly decreased.

THe combo they placed him and that he is still on is the best we have ever seen in him. He is on carbamazapine (tegretol), abilify, and guanfacine (tenex). THe tenex helps keep his hyperactivity (motor restlessness) at a manageable speed, and the abilify and tegretol seem to be working well together for the mood stabilizing piece.

Each kid is different (our difficult child got verbal and physical tics from clonidine!), but I thought it might be helpful to hear about as many different experiences as possible!
Good lluck!

 

[Nomad]

FWIW...
My difficult children doctor will not prescribe clonodine for her patients with bipolar disorder, but we have never discussed why.
Our child has had good luck with Seroquel...but it does make her sleepy. She uses it primarily to help her sleep.
Not sure what classification Geodon is in...but I recall being surprised when it caused her extreme agitation. I remember how the Dr. thought it would be a great medication for her and how the Dr. was getting good results with other patients. Wow...it was a huge problem for our child.
Our daughter was on Trileptal for awhile and only got minimal help with that medication. She was switched to Lamictal and it does seem to be a better match for her.
Hopefully the doctors. do the best they can with the prescribing information and then make decisions based on experience. But the trial and error part of this can be disheartening. However...all we can do is try our best. The last thing our kids and our families need is a few more rides on the roller coaster...so stay strong and make sure you 1) have a back up plan 2) wont hesitate to call the dr. if something goes wrong 3) have a good support system in place.

 

[CCRidr2]

It seems to do wonders for that BUT were were beginning to see increased agitation and agression and he's had some pretty severe rages.

My son had the same reaction to Vyvanse a couple of weeks ago. The problem with the medications that help with the ADHD can wreak real havoc with the mood disorders. in my opinion it's easier to deal with the ADHD than it is to deal with the unstable moods. HUGS!

CC

 

[Sara PA]

Geodon is an atypical antipsychotic (class of drugs aka "major tranquilizers") like Risperdal, Zyprexa, Seroquel and Abilify.