The Role of the Pharmacist in Fetal Alcohol Spectrum Disorder
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Transcript of The Role of the Pharmacist in Fetal Alcohol Spectrum Disorder
The Role of the Pharmacist in Fetal Alcohol Spectrum Disorder
Mansfield Mela
HISTORY OF FASD
DIAGNOSIS OF FASD
• PREVALENCE
• CLINICAL PICTURE
• MULTIPROESSIONAL
• ACCESS TO SUPPORT
• TERMINOLOGY (FAS, FAE, ARND, ARBD, FASD)
• BENEFIT OF DIAGNOSIS
• INTERVENTION
Biopsychosocial model-May & Gossage 2011
Alcohol and the developing central nervous system
Direct toxic effect leading to neural cell death and decreased brain volume
Impairs transport of glucose and amino acids
Derangement of chemical and hormonal systems controlling migration and maturation of cells
Mechanism of prenatal alcohol brain damage
Direct cell death: Apoptosis Vs. Necrosis
Reduced cell proliferation (glia cells)
Migration errors in brain development and gene expression
Inhibition of nerve growth factor
Disruption of neurotransmitters
Oxidative stress
Oxidative homeostasis is the way the body maintains the balance
between free radical (oxidants) production and antioxidant reserve.
Oxidative stress is the enhancement of the body’s production of
free radicals and other strong oxidants either by increased
production of the radical or by depletion of body stores of
antioxidants.
Alcohol and oxidative stress
Certain pathways of alcohol metabolism result in the
generation of ROS.
Alcohol may reduce antioxidant levels. Experimental evidence
suggests that these factors may contribute to alcohol-induced
cell damage and cell death in the fetus
( Guerri 1998; Henderson et al. 1995; Kotch et al. 1995)
Consider Medications for a Whole Body Disorder?
Psychiatric diagnoses rates
Authors: Streissguth’96, Famy 1998, O’Connor ‘02
0-40% 35-65% 57-75% 79-90%
Psychosis Bipolar /
MDD
ADHD/ADD Total Rates
Seeing differently
Why Psychostimulants?
• Described as “questionable”– Infante ‘11
• 50-90% of FASD meet diagnostic criteria for ADHD –Bhatara et al ‘06; – Freyer et al ’07
• Two crossover control trials –Oesterheld ‘98; Snyder ’97
• Amphetamine preferred to methylphenidate• Retrospective review evidence – Doig et al ‘08
• 40-79% of FASD on stimulants – Dalen ’09; Frankel ‘06
• Psychostimulants effective in attention deficits, impulsivity, oppositional, and conduct disordered symptoms common in FASD
Why Alpha-2-Adrenergic Agonist?Guanfacine & Clonidine
• Significantly decreased fine motor speed -Connor ’00
• Effective in managing sleep problems - Calles et al
’08
• Facilitate dopamine & norepinephrine neurotransmission
What About Non-Psychotropics?
• Choline improved executive functioning in toddlers in an RCT
• Iron
• Melatonin
• Thyroxine
• Who should you direct your prevention efforts to because using alcohol during pregnancy is more likely?
• Low education and low income
• High education and high income
• Rural, remote, Aboriginal, and inner-city communities
• Adolescent exploring sexuality
• University student being treated for STC
PREVENTION ROLE
• HAVE A “GOD LENS”
• WOMEN ON CONTRACEPTION
• Anything to do with sex
• REMEMBER: 50% of pregnancies are unplanned and alcohol use among child bearing women is high.
What comes to mind when a patient repeatedly comes back saying “my
meds got lost or stolen”?
Disappearing acts
• Blaming the dog
• Blaming the child
• Lost in the bus
• Washed away
• Muggers on the loose
• The strongest wind yet
• Border services fault
COUNSELLING ROLE
• LOST MEDICATION
• DIVERSION AND MISUSE
• SIDE EFFECTS LANGUAGE
• EXPLOITATION BY OTHERS
• SIMPLIFY DISENSING
• RESPONSIBLE OTHER
• DOSE ESCALATION
TAKE HOME POINTS
• For every twenty patients one has FASD
• For every two females at least one needs prevention counselling
• When “my meds are lost” think of FASD too
• Modify your language to comprehension level
• Simplify dispensing practices
• Initiate projects and research to support escalating and reducing doses
THANK YOU!!
Q & A