Manter Mariah A, Birtwell Kirstin B, Bath James, Friedman Nora D B, Keary Christopher J, Neumeyer Ann M, Palumbo Michelle L, Thom Robyn P, Stonestreet Emily, Brooks Hannah, Dakin Kelly, Hooker Jacob M, McDougle Christopher J
Lurie Center for Autism, Massachusetts General Hospital, Lexington, MA, 02421, USA.
Athinoula A. Martinos Center for Biomedical Imaging, Mass General Research Institute, Charlestown, MA, 02129, USA.
BMC Med. 2025 Jan 7;23(1):11. doi: 10.1186/s12916-024-03814-0.
The prevalence of autism spectrum disorder (ASD) has surged, with an estimated 1 in 36 eight-year-olds in the United States meeting criteria for ASD in 2020. Autistic individuals face elevated rates of co-occurring medical, psychiatric, and behavioral conditions compared to non-autistic individuals. The rising ASD-patient demand is increasingly outpacing the capacity of ASD-specialty clinics, resulting in urgent need for autism-competent providers in general practice settings. This work aims to empower healthcare providers, especially primary care providers (PCPs), with guidelines for the recognition and safe pharmacologic management of common co-occurring psychiatric and behavioral conditions in ASD.
Lurie Center for Autism medical providers, who have extensive experience in ASD care, delineated approaches for recognition and pharmacological treatment of sleep disturbances, attention-deficit/hyperactivity disorder (ADHD), anxiety, depression, and irritability tailored to ASD patients. Pharmacological guidelines were iteratively refined until consensus was reached. Treatment differences relative to standard of care (SOC) of non-autistic individuals are noted. Key literature and clinical trial results were reviewed to supplement clinical experience.
The pharmacological treatment pathways reflect how appropriate medication options for ASD patients can depend on many factors unique to the patient and can differ from established non-autistic SOC. Key takeaways include: For sleep disturbances in ASD, initial strategies align with non-autistic SOC, emphasizing sleep hygiene and melatonin use. First-line recommendations for treating ADHD, anxiety, and depression in ASD differ from non-autistic SOC; α-adrenergic agonists are more suitable than stimulants for some ASD-ADHD patients, buspirone and mirtazapine are preferred to selective serotonin reuptake inhibitors (SSRIs) for anxiety, and duloxetine, mirtazapine, bupropion, and vortioxetine are recommended ahead of SSRIs for depression. Addressing irritability in ASD requires interdisciplinary evaluation of contributing factors, and guanfacine, risperidone, or aripiprazole may be appropriate, depending on severity.
Recognition and treatment of co-occurring psychiatric and behavioral conditions in autistic patients must account for differences in clinical presentation and medication effectiveness and tolerability. Drawing on evidence-based clinical insights, these guidelines seek to support PCPs in making informed decisions when prescribing medications for ASD patients with co-occurring psychiatric and behavioral conditions, ultimately enhancing access to timely, comprehensive care for all individuals with ASD.
自闭症谱系障碍（ASD）的患病率激增，据估计，2020年美国每36名8岁儿童中就有1名符合ASD的诊断标准。与非自闭症患者相比，自闭症患者同时患有医学、精神和行为疾病的比例更高。ASD患者需求的不断增加，已逐渐超过了ASD专科诊所的服务能力，因此迫切需要在普通医疗环境中有能力诊治自闭症的医疗服务提供者。这项工作旨在为医疗服务提供者，尤其是初级保健提供者（PCP）提供指导方针，以识别和安全地药物治疗ASD中常见的共病精神和行为疾病。
卢里自闭症中心的医疗服务提供者在ASD护理方面拥有丰富经验，他们制定了针对ASD患者的睡眠障碍、注意力缺陷多动障碍（ADHD）、焦虑、抑郁和易怒的识别及药物治疗方法。药物治疗指南经过反复完善，直至达成共识。记录了相对于非自闭症个体的标准治疗（SOC）的治疗差异。回顾了关键文献和临床试验结果以补充临床经验。
药物治疗途径反映了ASD患者合适的药物选择如何取决于患者的许多独特因素，并且可能与既定的非自闭症SOC不同。主要要点包括：对于ASD中的睡眠障碍，初始策略与非自闭症SOC一致，强调睡眠卫生和褪黑素的使用。治疗ASD中的ADHD、焦虑和抑郁的一线推荐与非自闭症SOC不同；对于一些ASD-ADHD患者，α-肾上腺素能激动剂比兴奋剂更合适，对于焦虑症，丁螺环酮和米氮平优于选择性5-羟色胺再摄取抑制剂（SSRI），对于抑郁症，度洛西汀、米氮平、安非他酮和伏硫西汀比SSRI更推荐使用。解决ASD中的易怒问题需要对促成因素进行多学科评估，根据严重程度，胍法辛、利培酮或阿立哌唑可能是合适的。
识别和治疗自闭症患者中共病的精神和行为疾病，必须考虑临床表现、药物有效性和耐受性的差异。借鉴基于证据的临床见解，这些指南旨在支持初级保健提供者在为患有共病精神和行为疾病的ASD患者开处方时做出明智的决定，最终增加所有ASD患者获得及时、全面护理的机会。
