Psychotropic Medication Utilization Parameters for Children and Youth in Texas Public Behavioral Health (6th Version) Developed by: The Parameters Workgroup of the Psychiatric Executive Formulary Committee, Health and Specialty Care Division, Texas Health and Human Services Commission Review and Input Provided by: The University of Texas at Austin College of Pharmacy The UT System Medical Schools Texas A&M Health Science Center Texas Tech University Health Sciences Center June 2019 Table of Contents Table of Contents ........................................................................................... 2 Introduction and General Principles .................................................................. 5 Role of Primary Care Providers ............................................................... 7 General Principles ................................................................................. 7 Use of Psychotropic Medication in Preschool Age Children ........................... 9 Treatment of Opioid Use Disorders in Adolescents ................................... 10 Levels of Warnings Associated with Medication Adverse Effects ................. 11 Criteria Indicating Need for Further Review of a Child’s Clinical Status ....... 12 Usual Recommended Doses ........................................................................... 13 Stimulants for Treatment of ADHD ........................................................ 14 Amphetamine mixed salts ........................................................... 14 Amphetamine sulfate ................................................................. 14 Amphetamine base .................................................................... 14 Dextroamphetamine ................................................................... 15 Lisdexamfetamine ...................................................................... 15 Methylphenidate ........................................................................ 15 Other ADHD Treatments ...................................................................... 19 Atomoxetine.............................................................................. 19 Clonidine .................................................................................. 19 Guanfacine ................................................................................ 20 Bupropion ................................................................................. 21 Imipramine ............................................................................... 21 Tricyclic Antidepressant .............................................................. 22 Antidepressants – SSRIs ...................................................................... 22 Citalopram ................................................................................ 22 Escitalopram ............................................................................. 22 Fluoxetine ................................................................................. 23 Paroxetine ................................................................................ 23 Fluvoxamine.............................................................................. 23 Sertraline.................................................................................. 23 Vilazodone SSRI and 5-HT1A receptor partial agonist ..................... 24 Antidepressants – SNRIs ...................................................................... 24 Venlafaxine ............................................................................... 24 Duloxetine ................................................................................ 25 Desvenlafaxine .......................................................................... 25 Levomilnacipran ........................................................................ 25 Clomipramine ............................................................................ 25 Antidepressants – Other Mechanisms .................................................... 26 Mirtazapine ............................................................................... 26 Vortioxetine .............................................................................. 26 Selegiline .................................................................................. 26 Monoamine oxidase inhibitors (MAOIs) oral formulations ................ 27 St. John’s Wort .......................................................................... 27 Antipsychotics: Second Generation (Atypical) ......................................... 28 Aripiprazole .............................................................................. 28 Quetiapine ............................................................................... 28 Olanzapine ................................................................................ 28 Risperidone .............................................................................. 29 Clozapine ................................................................................. 29 Asenapine ................................................................................ 29 Iloperidone ............................................................................... 29 Paliperidone ............................................................................. 29 Ziprasidone .............................................................................. 30 Lurasidone ............................................................................... 30 Brexpiprazole ........................................................................... 30 Cariprazine ............................................................................... 30 Combination Antipsychotic-Antidepressant Formulation(s) ....................... 31 Olanzapine/ Fluoxetine ............................................................... 31 Antipsychotics: First Generation (Typical) .............................................. 33 Chlorpromazine ......................................................................... 33 Haloperidol ............................................................................... 33 Perphenazine ............................................................................ 33 Pimozide ................................................................................... 34 Mood Stabilizers ................................................................................. 35 Carbamazepine .......................................................................... 35 Divalproex Sodium ..................................................................... 36 Lithium ..................................................................................... 38 Lamotrigine ............................................................................... 39 Oxcarbazepine ........................................................................... 41 Lamotrigine Dosing ............................................................................. 41 Lamotrigine Dose Titration for Adolescents 10-12 years of age. ....... 41 Lamotrigine Dose Titration for Adolescents 13-17 years of age. ....... 42 Sedatives/Hypnotics ............................................................................ 43 Diphenhydramine ...................................................................... 43 Trazodone ................................................................................. 44 Eszopiclone ............................................................................... 45 Melatonin .................................................................................. 45 Ramelteon ................................................................................ 45 Hydroxyzine .............................................................................. 46 Suvorexant ............................................................................... 46 Zolpidem .................................................................................. 46 Benzodiazepines ........................................................................ 47 Special Considerations .................................................................................. 47 Titration of Antidepressant Medications .................................................. 47 Taper of Antidepressant Medications ..................................................... 48 Titration of Antipsychotic Medications .................................................... 49 Taper of Antipsychotic Medications ........................................................ 50 Levels of Evidence for Efficacy in Child & Adolescent Psychopharmacology .......... 51 Glossary ..................................................................................................... 52 References .................................................................................................. 54 Web Link References .................................................................................... 62 Members of the Workgroup ........................................................................... 63 Chairs 63 Members............................................................................................ 63 Committee Members Disclosures ........................................................... 64 Disclaimer ................................................................................................... 64 Acknowledgements ...................................................................................... 65 Introduction and General