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Medication

Medication Summary

Drugs to cure the core characteristics of Asperger syndrome have not yet been identified. Pharmacologic interventions are used to treat comorbid disorders, including attention problems and mood disorders (eg, dysthymia, bipolar disorder). Such interventions should not be prescribed in the absence of an indication. Agents that may be considered include the following:

Second-generation antipsychotics
Selective serotonin reuptake inhibitors (SSRIs)
Other psychiatric medications (eg, atomoxetine and guanfacine)

Class Summary

Antipsychotic medications may help reduce aggressive behavior.

Risperidone (Risperdal, Risperdal Consta, Risperdal M-tab)

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Risperidone is an atypical antipsychotic agent that is indicated for irritability associated with autistic spectrum disorder (ASD) in children and adolescents aged 5-16 years. It has high affinity for serotonin 5-HT2 receptors and binds to dopamine D2 receptors with 20 times lower affinity than that for 5-HT2 receptors. Risperidone alleviates negative symptoms of psychoses and has a lower incidence of extrapyramidal adverse effects than conventional antipsychotics do.

Paliperidone (Invega, Invega Sustenna)

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Paliperidone is the major active metabolite of risperidone and was the first oral agent to allow once-daily dosing. Its mechanism of action not completely understood but is thought to involve mediation of central antagonism of dopamine D2 and serotonin 5HT-2A receptors. Paliperidone also elicits antagonist activity at adrenergic alpha1 and alpha2 receptors and histamine H1 receptors. Paliperidone is available in an osmotic delivery capsule.

Aripiprazole (Abilify, Abilify Discmelt)

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The mechanism of action of aripiprazole is unknown but is hypothesized to differ from those of other antipsychotics. Aripiprazole is thought to be a partial dopamine D2 and serotonin 5-HT1A agonist and an antagonist of serotonin 5-HT2A. No QTc interval prolongation has been noted in clinical trials.

Class Summary

SSRIs may hasten recovery from depression in people with Asperger syndrome.

Fluvoxamine (Luvox CR)

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Fluvoxamine elicits its effects through inhibition of neuronal uptake of serotonin in the central nervous system (CNS). It is indicated for the treatment of obsessive-compulsive behavior in children and adolescents aged 8-17 years. Gender differences should be considered in pediatric patients; therapeutic effects may be achieved at lower doses in girls.

Fluoxetine (Prozac)

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The mechanism of action of fluoxetine involves inhibition of CNS neuronal uptake of serotonin, with minimal reuptake of norepinephrine or dopamine.

Sertraline (Zoloft)

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The mechanism of action of sertraline is linked to inhibition of CNS neuronal uptake of serotonin, with very weak effects on norepinephrine and dopamine neuronal reuptake.

Paroxetine (Paxil, Pexeva)

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Paroxetine is a potent selective inhibitor of neuronal serotonin reuptake. It also has a weak effect on norepinephrine and dopamine neuronal reuptake. For maintenance, the dosing should be adjusted so as to maintain the patient on the lowest effective dosage, and the patient should be periodically reassessed to determine the need for continued treatment.

Citalopram (Celexa)

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Citalopram enhances serotonin activity through selective reuptake inhibition at the neuronal membrane. No head-to-head comparisons of SSRIs have been done; however, on the basis of metabolism and adverse effects, citalopram is considered the SSRI of choice for patients with head injury.

Escitalopram (Lexapro)

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Escitalopram is an SSRI and an S-enantiomer of citalopram. It is used for the treatment of depression. Its mechanism of action is thought to be potentiation of serotonergic activity in the CNS, resulting from inhibition of CNS neuronal reuptake of serotonin. The onset of depression relief may be obtained after 1-2 weeks—sooner than is possible with other antidepressants.

Class Summary

Patients with Asperger syndrome who have inattention and distractibility may respond to second-line agents for attention-deficit/hyperactivity disorder (ADHD).

Atomoxetine (Strattera)

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Atomoxetine is a selective norepinephrine reuptake inhibitor (SNRI). It is not a stimulant but may be effective as adjunctive therapy for the comorbid ADHD associated with Asperger syndrome.

Guanfacine (Intuniv, Tenex)

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Guanfacine, an alpha2 agonist, may preferentially bind postsynaptic alpha2A adrenoreceptors in the prefrontal cortex, and this preferential binding may improve delay-related firing of prefrontal cortex neurons. As a result, guanfacine may affect behavioral inhibition. It has been used off label to reduce hyperactivity in children with Asperger syndrome.

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Author

James Robert Brasic, MD, MPH, MS, MA Assistant Professor, Russell H Morgan Department of Radiology and Radiological Science and Neurology, Division of Nuclear Medicine and Molecular Imaging, Assistant Professor, Department of Neurology, Johns Hopkins University School of Medicine

James Robert Brasic, MD, MPH, MS, MA is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, American Academy of Neurology, International Parkinson and Movement Disorder Society, Society for Neuroscience, Society of Nuclear Medicine and Molecular Imaging

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Johns Hopkins University School of Medicine; New York City Health and Hospitals/Bellevue, New York University Langone Health<br/>Serve(d) as a speaker or a member of a speakers bureau for: Society of Nuclear Medicine and Molecular Imaging, Maryland Regional Council of Child and Adolescent Psychiatry<br/>Received research grant from: National Institutes of Health, Johns Hopkins University School of Medicine, Intellectual & Developmental Disabilities Research Center (U54 HD079123) at the Kennedy Krieger Institute<br/>Received income in an amount equal to or greater than $250 from: Gerson Lehrman Group; Guidepost<br/>Received royalty from Medscape for other.

Coauthor(s)

Farzaneh Farhadi, MD Postdoctoral Research Fellow, Johns Hopkins Hospital

Disclosure: Nothing to disclose.

Chief Editor

Caroly Pataki, MD Health Sciences Clinical Professor of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, David Geffen School of Medicine

Caroly Pataki, MD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, New York Academy of Sciences, Physicians for Social Responsibility

Disclosure: Nothing to disclose.

Additional Contributors

Hongzhu Deng, MD, PhD Associate Professor, Department of Pediatrics, The Third Affiliated Hospital of Sun Yat-Sen University of Medical Sciences, China

Disclosure: Nothing to disclose.

Gregory N McKay Johns Hopkins University School of Medicine

Disclosure: Nothing to disclose.

Acknowledgements

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Asperger Syndrome Medication

Medication Summary

Antipsychotics, 2nd Generation

Class Summary

Risperidone (Risperdal, Risperdal Consta, Risperdal M-tab)

Risperidone (Risperdal, Risperdal Consta, Risperdal M-tab)

Paliperidone (Invega, Invega Sustenna)

Paliperidone (Invega, Invega Sustenna)

Aripiprazole (Abilify, Abilify Discmelt)

Aripiprazole (Abilify, Abilify Discmelt)

Selective Serotonin Reuptake Inhibitors

Class Summary

Fluvoxamine (Luvox CR)

Fluvoxamine (Luvox CR)

Fluoxetine (Prozac)

Fluoxetine (Prozac)

Sertraline (Zoloft)

Sertraline (Zoloft)

Paroxetine (Paxil, Pexeva)

Paroxetine (Paxil, Pexeva)

Citalopram (Celexa)

Citalopram (Celexa)

Escitalopram (Lexapro)

Escitalopram (Lexapro)

Psychiatric Agents, Other

Class Summary

Atomoxetine (Strattera)

Atomoxetine (Strattera)

Guanfacine (Intuniv, Tenex)

Guanfacine (Intuniv, Tenex)

Asperger Syndrome Medication

Medication Summary

Antipsychotics, 2nd Generation

Class Summary

Risperidone (Risperdal, Risperdal Consta, Risperdal M-tab)

Paliperidone (Invega, Invega Sustenna)

Aripiprazole (Abilify, Abilify Discmelt)

Selective Serotonin Reuptake Inhibitors

Class Summary

Fluvoxamine (Luvox CR)

Fluoxetine (Prozac)

Sertraline (Zoloft)

Paroxetine (Paxil, Pexeva)

Citalopram (Celexa)

Escitalopram (Lexapro)

Psychiatric Agents, Other

Class Summary

Atomoxetine (Strattera)

Guanfacine (Intuniv, Tenex)

References

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