Anxiety and OCD — Medication Management Recommendations — Clinical Pathway: Outpatient Behavioral Health and Primary Care

Anxiety Disorder and OCD Clinical Pathway — Outpatient Behavioral Health and Primary Care

Medication Management Recommendations

Consenting for Medication

Consent
  • Prior to initiation of medication, use mutual decision making to review:
    • Benefits and risks of the medication
    • Alternatives to the medication
    • Risks of not treating and benefits of treating
    • Review FDA recommendation for prescribers to alert caregivers about the need to closely monitor patients for:
      • Clinical worsening, suicidality
      • Unusual changes in behavior
    • This is especially important during initiation of drug therapy or following dose adjustments.
    • Review of evidence-based studies in pediatrics
Document
  • Document that the discussion occurred, and if patient/caregiver chooses to proceed with treatment
  • To the extent possible, make the plan with the cooperation, understanding, consent of the patient

General Guidance for Medication Initiation

  • SSRIs are the 1st line medications for treating moderate/severe anxiety disorders and OCD in children and adolescents
  • FDA Approval/Evidence
    • Use of SSRIs for anxiety treatment are based on ample evidence
    • No SSRIs are FDA approved to treat core anxiety disorders in pediatric
    • Sertraline and Fluoxetine are FDA approved to treat Pediatric OCD
  • While SSRIs are not FDA approved for the core anxiety disorders, there is ample clinical evidence of safety and efficacy in using SSRIs for pediatric anxiety disorders
  • Do not use with MAOIs (monoamine oxidase inhibitors)
  • Recommend starting with lower doses in younger children
  • If no clinical response to 1st line, PCP can consider consulting psychiatry
  • Sertraline and Fluoxetine are available in liquid formulation
  • Duloxetine is available in both capsule and sprinkle. Capsules may be added to liquids, and sprinkle may be added to food
  • For additional information on medications, please refer to formulary  

SSRI/SNRI Medication Dosing Recommendations and Adverse Effects

1st Line SSRI Selective Serotonin Reuptake Inhibitor
Sertraline
ZoloftTM		 FDA Approved Indication/Age OCD, Age ≥ 6 years
Typical Dosing Range
Children 25 - 100 mg
Adolescents 50 - 150 mg
Typical Starting Dose 12.5 mg - 25 mg daily
Typical Titration Increments 12.5 – 25 mg for doses < 50 mg
25 mg for doses > 50 mg
Max Daily Dose 200 mg
Common Adverse Effects GI upset, headaches, insomnia
Fluoxetine
ProzacTM		 FDA Approved Indication/Age MDD, OCD, Age ≥ 8 years
Typical Dosing Range
Children 5 - 10 mg
Adolescents 10 - 40 mg
Typical Starting Dose 5 - 10 mg daily
Typical Titration Increments 5 mg for doses < 20 mg
10 mg for doses > 20 mg
Max Daily Dose 60 mg
Common Adverse Effects Nausea, headache, weight reduction, abdominal pain
2nd Line SNRI Serotonin-norepinephrine Reuptake Inhibitor
Duloxetine
CymbaltaTM		 FDA Approved Indication/Age GAD, Age ≥ 7 years
Typical Dosing Range
Children, Adolescents 30 - 60 mg
Typical Starting Dose 20 - 30 mg daily
Typical Titration Increments 20 - 30 mg
Max Daily Dose 120 mg
Common Adverse Effects Nausea, headache, weight reduction, abdominal pain

Titration Tips:
Initial increase: Can increase dose after 2 - 4 weeks after ensuring tolerability
Subsequent increases: Would wait 4 - 8 weeks between dose adjustments to allow medication to reach steady state before assessing for efficacy

Rare Potential Serious Side Effects

SSRI Serotonin Syndrome, suicidal thoughts
SNRI Serotonin Syndrome, suicidal thoughts, hepatic failure

Please refer to CHOP formulary   for detailed list of possible adverse effects.