Recent research from CanFASD, the national Fetal Alcohol Spectrum Disorder (FASD) research network in Canada, has developed guidelines for clinicians to follow when prescribing medications to people with FASD (Mela et al., 2020). An expert panel, guided by previous research, developed an algorithm which aims to streamline medication prescription and prevent the negative effects of overprescribing (Mela et al., 2018). When the correct balance is achieved, medication can be highly beneficial in supporting (not replacing) social and behavioural interventions.
The complex, multidomain impacts of FASD can make pharmacological intervention difficult. People with FASD often end up taking numerous medications at the same time, a practice known as polypharmacy. When the correct balance of medications is not achieved, polypharmacy can cause physical discomfort and emotional distress. Finding the correct balance of medications can change over time as people’s health, environment, habits and bodies change.
Medications that impact cognition (thought processes), mood, behaviour, and perception (the way you interpret what you see, hear, smell, taste, and feel), are known as psychotropic medications. This group of medications includes antianxiolytics, antidepressants, antipsychotics/neuroleptics, mood stabilisers, and stimulants. Each of these medications can impact brain function in different ways so are used to target different specific domains affected by FASD.
Prescribing psychotropic medications can be difficult because everyone responds differently. If medications are prescribed to someone with FASD it is important for the individuals and parents or carers to discuss any changes, positive or negative, with the prescribing doctor at regular reviews. These reviews will help the doctor adjust the medications to find the best balance for the individual, which may take some time. It is very important to understand that many psychotropic medications cannot be stopped abruptly. If the medication is causing negative side effects these can become worse if the medication is stopped; discuss with the prescribing doctor the safest way to decrease the medication.
The algorithm developed to guide the integration of medication into FASD treatment includes five stages:
Stage 1 – Diagnosis and nonpharmacological interventions.
| Targeted domains | Outcome |
| Academic performance
Adaptive functioning Affect regulation Attention Cognition Executive functioning Language Memory Motor skills |
Reduced stress
Improved behaviour and responsiveness Increased meaningful engagement in school, work, and relationships |
Stage 2 – Domain-specific pharmacological intervention. Maximum two medications for children and four for adults.
| Domain | Signs & Symptoms | Treatment |
| Hyperarousal | Hypervigilance
Aggression Insomnia Irritability Agitation Anger Anxiety Tension Reduced pain threshold |
Adrenergic Agent
· Clonidine · Guanfacine |
| Emotion Regulation | Mood swings
Excitability Anxiety Depression |
Mood Stabiliser
· Divaloprex · Lamotrigine |
| Hyperactive/ Neurocognitive | Restless movement
Impulsiveness Inattention Executive dysfunction |
Amphetamine Based Stimulants
· Lisdexamfetamine · Dexedrine |
| Cognitive Inflexibility | Impairments in:
Perspective taking Frustration tolerance Social skills Reasoning Reality testing Abstraction |
Atypical Neuroleptic
· Risperidone* |
*NOT FOR USE IN CHILDREN
Stage 3 – Domain-specific pharmacological intervention plus primary and secondary domain-specific intervention. These additional medications should not exceed the limit of two medications for children and four for adults.
| Domain | Treatment |
| Hyperarousal | SSRI
· Fluoxetine* · Citalopram* · Sertraline* |
| Emotion Regulation | SSRI
· Fluoxetine* · Citalopram* · Sertraline* |
| Hyperactive/ Neurocognitive | Other Stimulants
· Methylphenidate · Atomoxetine · Bupropion |
| Cognitive Inflexibility | Atypical Neuroleptic
· Olanzapine · Aripiprazole |
*NOT FOR USE IN CHILDREN
Stage 4 – Traditional treatment algorithms for comorbid disorders such as depression and anxiety, and Attention Deficit Hyperactivity Disorder.
Stage 5 (ADULTS ONLY) – Consider adjunctive medications but note there is minimal research supporting these recommendations. These medications include:
| Signs & Symptoms | Treatment |
| General | Nutritional Supplement
· Omega-3 · Choline · Iron · Glutamine Cannabinoid · Cannabidiol |
| Insomnia | Antidepressant
· Mirtazapine · Trazodone Amino Acid · Tryptophan |
| Cognition | Tetracycline Antibiotic
· Minocycline |
| Mood | Mood Stabiliser
· Vortioxetine |
| Hyperarousal | Alpha Blocker
· Prazosin Beta Blocker · Propranolol |
Mela and colleagues (2020) research is the first step in defining a staged medication approach to treat FASD. More research will be required over the next decade to review its success in reducing polypharmacy and improving the daily life of people living with FASD.
If you are a parent, carer, or person living with FASD and you have questions about medications, speak to your treating clinicians.
If you are a doctor using this prescription algorithm, the authors would like to hear your feedback. Please contact Dr Mela Mansfield on mansfieldmela@gmail.com.
Read more NOFASD Australia blogs
References
Mela, M., Hanlon-Dearman, A., Ahmed, A. G., Rich, S., Densmore, R., Reid, D., Barr, A., Osser, D., Anderson, T., Suberu, B., Ipsiroglu, O., Rajani, H., & Loock, C. (2020). Treatment algorithm for the use of psychopharmacological agents in individuals prenatally exposed to alcohol and/or with diagnosis of fetal alcohol spectrum disorder (FASD). Journal of Population Therapeutics and Clinical Pharmacology, 27(3), e1–e13. https://doi.org/10.15586/jptcp.v27i3.681
Mela, M., Okpalauwaeke, U., Anderson, T., Eng, J., Nomani, S., Ahmed, A., & Barr, A. (2018). The utility of psychotropic drugs on patients with Fetal Alcohol Spectrum Disorder (FASD): A systematic review. Psychiatry and Clinical Psychopharmacology, 28(4), 436-445. https:// 10.1080/24750573.2018.1458429
