BNF for Children 2011-2012

186 4.3.3 Selective serotonin re-uptake inhibitors BNFC 2011–20124 Central nervous systemIndication and doseNocturnal enuresis. By mouthChild 6–8 years 25 mg at bedtimeChild 8–11 years 25–50 mg at bedtimeChild 11–18 years 50–75 mg at bedtimeNote Max. period of treatment (including gradual withdrawal)3 months—full physical examination beforefurther course, see also section 7.4.2Attention deficit hyperactivity disorder (underspecialist supervision). By mouthChild 6–18 years 10–30 mg twice dailyImipramine (Non-proprietary) ATablets, coated, imipramine hydrochloride 10 mg, netprice 28-tab pack = £1.30; 25 mg, 28-tab pack = £1.24.Label: 2Oral solution, imipramine hydrochloride 25 mg/5 mL, net price 150-mL = £20.00. Label: 2NORTRIPTYLINECautions see notes above; manufacturer advisesplasma-nortriptyline concentration monitoring if doseabove 100 mg daily, but evidence of practical valueuncertainContra-indications see notes aboveHepatic impairment see notes abovePregnancy use only if potential benefit outweighs riskBreast-feeding see notes aboveSide-effects see notes above; also abdominal pain,stomatitis, diarrhoea, hypertension, oedema, flushing,restlessness, fatigue, and mydriasisIndication and doseDepression (but see notes above). By mouthChild 12–18 years low dose initially increased asnecessary to 30–50 mg daily in divided doses or asa single dose (max. 150 mg daily)Allegron c (King) ATablets, nortriptyline (as hydrochloride) 10 mg, netprice 100-tab pack = £12.06; 25 mg (orange, scored),100-tab pack = £24.02. Label: 24.3.2 Monoamine-oxidaseinhibitors(MAOIs)Classification not used in BNF for Children.4.3.3 Selective serotonin reuptakeinhibitorsCitalopram, fluoxetine, fluvoxamine, and sertralineselectively inhibit the re-uptake of serotonin (5-hydroxytryptamine,5-HT); they are termed selective serotoninre-uptake inhibitors (SSRIs).Depressive illness in children and adolescentsThe balance of risks and benefits for the treatment ofdepressive illness in individuals under 18 years isconsidered unfavourable for the SSRIs citalopram,escitalopram, paroxetine, and sertraline, and formirtazapine and venlafaxine. Clinical trials havefailed to show efficacy and have shown an increasein harmful outcomes. However, it is recognised thatspecialists may sometimes decide to use these drugsin response to individual clinical need; children andadolescents should be monitored carefully for suicidalbehaviour, self-harm or hostility, particularly atthe beginning of treatment. Only fluoxetine hasbeen shown in clinical trials to be effective fortreating depressive illness in children and adolescents.However, it is possible that, in common withthe other SSRIs, it is associated with a small risk ofself-harm and suicidal thoughts. Overall, the balanceof risks and benefits for fluoxetine in the treatment ofdepressive illness in individuals under 18 years isconsidered favourable, but children and adolescentsmust be carefully monitored as above.Cautions SSRIs should be used with caution in childrenwith epilepsy (avoid if poorly controlled, discontinueif convulsions develop), cardiac disease, diabetesmellitus, susceptibility to angle-closure glaucoma, ahistory of mania or bleeding disorders (especially gastro-intestinalbleeding), and if used together with otherdrugs that increase the risk of bleeding. They shouldalso be used with caution in those receiving concurrentelectroconvulsive therapy (prolonged seizures reportedwith fluoxetine). SSRIs may also impair performance ofskilled tasks (e.g. driving). Interactions: Appendix 1(antidepressants, SSRI).Withdrawal Gastro-intestinal disturbances, headache,anxiety, dizziness, paraesthesia, electric shock sensationin the head, neck, and spine, tinnitus, sleep disturbances,fatigue, influenza-like symptoms, and sweating are themost common features of abrupt withdrawal of an SSRIor marked reduction of the dose; palpitation and visualdisturbances can occur less commonly. The dose shouldbe tapered over a few weeks to avoid these effects. Itmay be necessary to withdraw treatment over a longerperiod; consider obtaining specialist advice if symptomspersist.Contra-indications SSRIs should not be used if thechild enters a manic phase.Pregnancy Manufacturers advise that SSRIs shouldnot be used during pregnancy unless the potentialbenefit outweighs the risk. There is a small increasedrisk of congenital heart defects when SSRIs are takenduring early pregnancy. If SSRIs are used during thethird trimester there is a risk of neonatal withdrawalsymptoms, and persistent pulmonary hypertension inthe newborn has been reported.Side-effects SSRIs are less sedating and have fewerantimuscarinic and cardiotoxic effects than tricyclicantidepressant drugs (section 4.3.1). Side-effects of theSSRIs include gastro-intestinal effects (dose-related andfairly common—include nausea, vomiting, dyspepsia,abdominal pain, diarrhoea, constipation), anorexiawith weight loss (increased appetite and weight gain