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