Initial pharmacotherapy for obsessive compulsive disorder in children
Follow the approach to managing obsessive compulsive disorder (OCD) in children. Psychosocial interventions are first line for OCD. Consider pharmacotherapy if there is insufficient response to psychosocial interventions, or symptoms are severe and causing significant impairment. Pharmacotherapy is ideally started by a clinician with expertise in using psychotropics in children. If a drug is required, use it concurrently with psychosocial interventions if possible. Selective serotonin reuptake inhibitors (SSRIs) are first-line drugs; however, paroxetine is not recommended in children because it has been associated with an increased risk of suicidal thoughts and behaviours, and other serious adverse events.
OCD symptoms can worsen after starting drug therapy and many patients do not experience symptom relief for 4 to 8 weeks—provide support and close monitoring during this time.
There is limited evidence to guide dosing of SSRIs in children. The dosage regimens in these guidelines are predominantly based on expert opinion and are included as a guide to suitable dosing. If the dosage regimens in these guidelines prove inadequate (eg higher doses are needed), expert advice should be sought because alternative regimens may be appropriate.
Starting patients on a low dose may help to decrease initial adverse effects (eg nausea, restlessness, agitation). However, the use of a lower starting dose prolongs the time taken to achieve therapeutic effect. See here for information on managing adverse effects.
Do not use pharmacotherapy for OCD in children 6 years or younger.
In children older than 6 years and younger than 12 years, if pharmacotherapy is considered necessary for OCD, use:
1 citalopram 10 mg orally, in the morning. Assess the patient’s response to therapy after 2 to 4 weeks to determine whether dose adjustment is needed. If it is, increase the daily dose by 5 to 10 mg no more often than every 2 weeks until an acceptable response is achieved or a daily dose of 20 mg is reached. If there is an acceptable response, continue at the same dose for 6 months, then consider deprescribing obsessive compulsive disorder (child) citalopram
OR
1 escitalopram 5 mg orally, in the morning. Assess the patient’s response to therapy after 2 to 4 weeks to determine whether dose adjustment is needed. If it is, increase the daily dose by 2.5 to 5 mg no more often than every 2 weeks until an acceptable response is achieved or a daily dose of 10 mg is reached. If there is an acceptable response, continue at the same dose for 6 months, then consider deprescribing obsessive compulsive disorder (child) escitalopram
OR
1 fluoxetine 10 mg orally, in the morning. Assess the patient’s response to therapy after 2 to 4 weeks to determine whether dose adjustment is needed. If it is, increase the daily dose by 5 to 10 mg no more often than every 2 weeks until an acceptable response is achieved or a daily dose of 30 mg is reached; however, up to 60 mg may be used under specialist supervision. If there is an acceptable response, continue at the same dose for 6 months, then consider deprescribing obsessive compulsive disorder (child) fluoxetine
OR
1 fluvoxamine 25 mg orally, at night. Assess the patient’s response to therapy after 2 to 4 weeks to determine whether dose adjustment is needed. If it is, increase the daily dose by 12.5 to 25 mg no more often than every 2 weeks until an acceptable response is achieved or a daily dose of 200 mg is reached. Doses above 50 mg daily may be given in divided doses for better tolerability. If there is an acceptable response, continue at the same dose for 6 months, then consider deprescribing obsessive compulsive disorder (child) fluvoxamine
OR
1 sertraline 25 mg orally, in the morning. Assess the patient’s response to therapy after 2 to 4 weeks to determine whether dose adjustment is needed. If it is, increase the daily dose by 12.5 to 25 mg no more often than every 2 weeks until an acceptable response is achieved or a daily dose of 200 mg is reached. If there is an acceptable response, continue at the same dose for 6 months, then consider deprescribing. obsessive compulsive disorder (child) sertraline
When deciding upon a suitable dosing regimen in children 12 years and older, consider the child’s developmental (physical) maturity—developmental maturity can vary between individuals of the same age (eg some 12-year-olds might be metabolically similar to young children, whereas others are similar to adults). At the lower end of the dose range, the recommended doses approximate those used in younger children. If the dosage regimens in these guidelines prove inadequate (eg higher doses are needed), seek expert advice—the doses of SSRIs required to effectively treat OCD are often higher than the doses for other indications. In children 12 years and older, if pharmacotherapy is considered necessary for OCD, use:
1 citalopram 10 to 20 mg orally, in the morning. Assess the patient’s response to therapy after 2 to 4 weeks to determine whether dose adjustment is needed. If it is, increase the daily dose by 10 mg no more often than every 2 weeks until an acceptable response is achieved or a daily dose of 40 mg is reached. If there is an acceptable response, continue at the same dose for 6 months, then consider deprescribing citalopram
OR
1 escitalopram 5 to 10 mg orally, in the morning. Assess the patient’s response to therapy after 2 to 4 weeks to determine whether dose adjustment is needed. If it is, increase the daily dose by 5 mg no more often than every 2 weeks until an acceptable response is achieved or a daily dose of 20 mg is reached. If there is an acceptable response, continue at the same dose for 6 months, then consider deprescribing escitalopram
OR
1 fluoxetine 10 to 20 mg orally, in the morning. Assess the patient’s response to therapy after 2 to 4 weeks to determine whether dose adjustment is needed. If it is, increase the daily dose by 10 mg no more often than every 2 weeks until an acceptable response is achieved or a daily dose of 60 mg is reached. If there is an acceptable response, continue at the same dose for 6 months, then consider deprescribing fluoxetine
OR
1 fluvoxamine 25 to 50 mg orally, at night. Assess the patient’s response to therapy after 2 to 4 weeks to determine whether dose adjustment is needed. If it is, increase the daily dose by 25 mg no more often than every 2 weeks until an acceptable response is achieved or a daily dose of 200 mg is reached. Doses above 50 mg daily may be given in 2 divided doses for better tolerability. If there is an acceptable response, continue at the same dose for 6 months, then consider deprescribing fluvoxamine
OR
1 sertraline 25 to 50 mg orally, in the morning. Assess the patient’s response to therapy after 2 to 4 weeks to determine whether dose adjustment is needed. If it is, increase the daily dose by 25 mg no more often than every 2 weeks until an acceptable response is achieved or a daily dose of 200 mg is reached. If there is an acceptable response, continue at the same dose for 6 months, then consider deprescribing. sertraline