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Virtual Didactic - Pharmacotherapy in mTBI present ...
Virtual Didactic - Pharmacotherapy in mTBI Led by ...
Virtual Didactic - Pharmacotherapy in mTBI Led by Mary Alexis Iaccarino, MD
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looks great. Okay. All right. Well, welcome everyone. This is really exciting. My name is Alexis Icarino and I'm a department of PM&R at Spalding and Harvard and I have clinical practice in mild TBI across multiple groups, sport, kids, adults, military service members, and we're going to talk a little bit about using medication in the mild TBI population. I understand this is being recorded and that you guys will hopefully have access to this, but I just want to ask that you use it as a reference but don't make a copy or use of the slides. This is not a CME talk, but I left up some disclosures. None of them are really relevant to this at all. Again, mute your line when you're not talking. Questions can go through Sterling and don't distribute the slides. Just a note, we're discussing off-label use of medication. This is common in PM&R that we use a lot of medications off-label, but a lot of what we're talking about here is off-label. These slides are in part prepared by some of my colleagues at Spalding. I just want to give them credit for helping to compile a lot of this information. A word on mild TBI for everybody. Mild TBI is something that a lot of you are going to see in practice. If you go into sports medicine, you're going to see it. If you go into pediatrics, you're going to see it. If you go into general PM&R, you're going to see it. If you go into TBI, you're going to see it. Mild TBI is like 80 plus percent of all TBI. We as physiatrists are very well positioned to help take care of these people because we have a knowledge base that spans both understanding the neurological injury, but then also how to deal with a plug for all of you who are considering incorporating MTBI into your practice. We're going to divide this into three sections, physical, emotional, and cognitive. That's how I think of MTBI in those three buckets. We'll talk about medications in those buckets. I'll stop after each one. We'll allow for some questions. We'll try to wrap this up on time. Understand, first of all, that medication is not the mainstay of treatment for a concussion or mild TBI. For reference, I'm going to use those words interchangeably, concussion and mild TBI. The mainstay of treatment is behavioral and environmental adaptation. There are no evidence-based pharmacotherapies for the disorder of mild TBI or concussion. There's, at this time, no pill that we can give people that we know will cure or that we know for sure will hasten their recovery, although we'll talk about different medications that can be helpful. Pharmacology targets and treats symptoms, such as why I break it up into those three buckets of physical, cognitive, and emotional. Indications for pharmacology, or when should you start thinking about prescribing medication? We'll talk about it for different symptoms, but think about it when you've given the mainstay, which is behavioral and environmental adaptation, and it's not sufficient. You've coached your patient. You've gotten them to change some things about their work schedule, their school schedule, their athletics, or other things. You've given them ways to reduce maybe light noise exposure or to engage in PT or other sorts of things, and they're still not getting better, or when symptoms are severe, so maybe early in the course when someone's having severe headaches that are refractory to other non-pharmacologic headache interventions. So think about medication in those instances. I just want to add one more comment that this is not meant to be an exhaustive review of the literature or every single study or drug that's ever been tried for mild TBI. I'm trying to hit some of the high points and what's commonly done, but if you see here that I've skipped a study that you know about, you can always feel free to to send it on to the group, but this is not an exhaustive or systematic review. So I want to start with physical symptoms, and I want to start with headache. Headache is overwhelmingly the most common thing we see people complain about after a mild TBI or concussion. Mild headaches are absolutely expected. Severe headaches can be debilitating or keep people from participating in their recovery, and so we think about treating those. I like to use a headache tool to help monitor a patient's headache symptoms other than just asking them how they're feeling or using maybe a visual analog pain scale. My preference is the HIT6, which you can look up. It's a nice inventory, and it divides people into people whose headaches are controlled enough versus people that have moderate to severe headaches that impair function and maybe should be started on medication. These are your behavioral modifications listed here. You can run through them, but these are all the things that you should be trying at the outset before, you know, jumping right into medication or using them concurrently with medication. And there's some gray lines appearing on my screen. I don't know if they're appearing on anyone else's screen, but I think we'll just ignore them. Oh, and they seem to be persistent. We'll work on that. Let's see here. Okay. Well, so a little more about headache medications, right? So in the beginning after maybe somebody's in the acute phase of MTBI or concussion, over-the-counter analgesics can be really helpful. They can reduce the severity of headaches. They're short on and off. At this time, there's no specific abortive or prophylactic medication that is approved or specifically indicated in the post-traumatic headache, okay? What we do when we try to think about what medication to use for the post-traumatic headache is to get a history and think about what does this headache, what does this post-traumatic headache mimic? So what kind of primary headache does it mimic? So your primary headaches are your migraines, your tension type, and others. And you want to get a feel for what are the characteristics of this post-traumatic headache and which of the primary types are they mimicking? And that can help guide you on which medications to try. As well, you want to think about the presence of comorbid symptoms, and we'll talk about that. Here's a little layout of the two kinds of medications you can think about prescribing. So you can think about treating headaches abortively, just getting rid of the headache that's occurring, versus prophylactically to try to reduce frequency and severity over time. In the beginning of a concussion, abortive treatments are probably where you're going to go. And then if you have patients who have prolonged or persistent symptoms, who get in the chronic phase of headache, you may be thinking of moving towards something prophylactic. And these are sort of your options, and we're going to go through them in a little bit more detail. I want to make a quick comment about something called medication overuse headache. So there is a variety of literature on how much medication overuse headache plays into people presenting with headaches, but I think there's enough literature out there to support discussing it and thinking about it. So medication overuse headache is a headache that's actually induced or exacerbated by using medications to treat headache. So in definition, it's the use of analgesics on 15 or more days per month for greater than three months. However, I think we can see it a lot earlier. Some of your big culprit medications for this, acetaminophen, your combination analgesics, so things that combine caffeine with barbiturates or caffeine with NSAIDs, and then opioids certainly. This can be a troublesome thing because you hear the patient say that they're feeling very, they're having terrible headaches, they take medication, it goes away, and then as soon as the medication wears off, the headache comes right back. And this might be a time that you start thinking about medication overuse headache. So just keep that in mind when you're thinking about prescribing your analgesics, your over-the-counter analgesics at least, in your abortive medicines, that if you have people start taking them around the clock, they could get into a cycle that could produce medication overuse headache. Treating this can be sometimes difficult, but you have to stop the abortive medications, and it can take sometimes quite a while for this to really clear up. So let's talk a little bit about migraines. So when people have post-traumatic headaches that have migrainess features, and we're not going to go into detail on the features, but you can think about addressing them two ways. Abortive medications, so for mild and moderate migraines, you might think about NSAIDs or your combination analgesics. In people who have severe migraine, or perhaps in people who have a history of migraine prior to the concussion, you might think about using things like your triptans. Apologies, I just lost my screen. Did anybody else lose my screen? Sterling, can you guys still see me? I can see you. Would you mind sharing your screen again? Yeah, I'm not sure what happened there. Apologies, guys. Okay, are we back? We're back. Great. Okay, here's an example of some of your triptans. In the treatment of post-traumatic headache with migrainess features, there's not a specific triptan that's more indicated than another. I think you have to understand about triptans is they come in a variety of delivery methods, oral versus mucosal. Some are injectable, and depending on your comfort level and your practice, you may or may not consider prescribing these. Important things when you think about some of these headache medicines, particularly the migraine medicines, you want an adequate dose and trial. You want to take the medication as soon as the headache occurs. For your triptans, patients should be taking those as soon as they feel their headache coming on. For some of the rapidly absorbing triptans, people will tell you that they can feel some unusual symptoms, nausea, fatigue, and occasionally you might need to give somebody an anti-emetic for that. The non-oral routes that have much faster absorption are going to give you a little bit more of those features, and then there's some contraindications to using particularly triptans. There's some increased risk of stroke and other things that you need to think about when you're prescribing those. I tend to work in a sport population. It's generally a young, healthy group, but if you're working with older adults or people with a lot of comorbidities, you're going to want to keep that in mind. Your prophylactic migraine agents, and these are also medications that even in non-migraine cases, we tend to give a try. Each of them has their pluses and their minuses, and I tried to summarize that a little bit here for you to review at a later time. Nortriptyline and amitriptyline are often the go-to in mild traumatic brain injury. Amitriptyline may also help with insomnia, so people having co-occurring sleep difficulty. It is an old antidepressant, but remember that the doses we use for headache are much lower than those that are likely useful for mood. Some things to think about when you prescribe tricyclic antidepressants like these are that arrhythmias are a possibility, and that if patients are in any way at risk for overdose, these can be lethal. Here's some sort of prescribing information at the bottom. I think remember with all these medications, you want to start low, go slow. That's your motto, but you can get up to reasonably high doses over time if you're looking to get max effect. Topiramate is another prophylactic agent. It goes by the brand name Topamax, and some people also know it as Dopamax. I think that Topiramate gets a bad rap. It can be a good headache drug for some people. It does have the potential for cognitive side effects, particularly slowing reaction time and slowed thinking, and that you can even see on neurocognitive testing if people are on Topamax for a while. I have other patients who respond really well to Topiramate, so I wouldn't cross it off your list or take it out of your toolbox, but it may not be your go-to in somebody who's already experiencing some cognitive difficulties. The other thing is to remember that it's pregnancy category D in your young female patients. Propranolol is a drug I use very commonly. It is FDA approved for migraine. It may not be your go-to in your athletes, in your sport concussion patients. It's going to slow heart rate a little bit. It can make people a little bit lethargic maybe. People complain about that with beta blockers, but certainly if you're working in the VA or in a military population where folks have co-occurring anxiety or post-traumatic stress disorder, I found propranolol to be a very useful agent. Some dosing information is listed here, but I generally tend to start people at a really low dose, make sure they're not going to get radicardic or orthostatic, and then titrate up. It's TID dosing in its smaller quantities like 10 and 20 milligrams, so it's not until you get to larger dosing that people can take it once a day, which can sometimes make it hard for people to comply with multiple time a day dosing, so keep that in mind. Neuralgic headaches. Leaving migraine and talking about headaches that are more neuralgic, this is not uncommon after a trauma to the head. You can get occipital neuralges, you can get orbital neuralges. These headaches are maybe, I think, a little bit easier to treat because you can block the nerve that's involved. In terms of pharmacotherapy, think about things you would otherwise prescribe for neuralgia, so your NSAIDs, gabapentin, and even in some cases carbamazepine, which is mostly used to treat things like primary trigeminal neuralgia, but can be tried if people have refractory neuralgic headaches. Cervically-mediated headaches. Remember, myofascial pain that contributes to whiplash can radiate into the head. Problems at the C2, C3 level will radiate up into the head, so bear all that in mind. These will often present like tension, unilateral, bilateral, bilateral, and these are usually best served at the outset with non-pharmacological treatments. Your manual modalities, PT, but if you do need to try something, short-term use of muscle relaxers is very reasonable. Your over-the-counter analgesics are reasonable, and maybe even gabapentin if there's a co-occurring neuralgic component, which there can be. I'm going to stop really quick because that's the end of talking about headaches, and we're going to move on to some medications you might use for mood. Sterling, I can't see the comments, so if you want to read questions to me, I'm happy to try to answer them or if people have comments. Yeah, I do have a couple of questions. One is for medication overuse headache, so how do you convince these patients to come off their offending medications, specifically if they don't want opioids to be taken out of their cold, dead hands? So, I think that's a good point. So, one thing I'll say is opioids are really never a great choice in mild TBI. If your patients end up with them from the ED or from another provider, that's tough because they may find them to be very helpful in the short term. So, there's a couple strategies. So, I tell patients, like, look, this is going to be unpleasant for a couple of days, but then you're going to find that your headaches are significantly better, and I can convince some people that way. There is a little bit of data that you can use steroids if people are having severe debilitating headaches from overuse. You can use a short course of steroids to get them through that period where they're coming off of the offending medication. I'll tell you in my practice, I've done it a couple of times, and I've had mixed results. Okay, thank you. How quickly can you go up on a TCA for prophylaxis, you know, if 10 or 25 milligrams isn't helping? So, I tend to go up every two to three weeks. It's a little bit slow, but I always want to make sure that we're not getting any side effects. Okay, and Amovig, have you had any success with that in TBI migraines? Yeah, great question. So, I have not used Amovig in my practice yet. I have read about it. I've had patients who have come to me on Amovig from their headache specialist, and I think that for patients who have refractory headaches that have gone through using some of our more common agents, you know, certainly Amovig, you know, could be a possibility. One thing I would refer people to if you want to have a sort of treatment algorithm for when to try different drugs or what's first line and what's second line and what's third line is the Ontario Neurotrauma Foundation guidelines, which are publicly available on the internet, has a very nice section on post-traumatic headache and has a, basically, like a little flow sheet decision tree on what drugs to use and when. So, I definitely refer people to that, but I think there are patients who are going to have refractory headaches who are going to move through all the drugs we've discussed, and then something like Amovig would definitely be on your radar. I don't know about using it first line. Thank you, and lastly, I think we can, we'll need to move on to the next section, but any indication for chemodenervation, any sort of procedures that might be helpful, like occipital block or anything like that that you're aware of? Yeah, absolutely. So, again, off-label use and kind of outside the scope of a pharmacology talk, but certainly if you have people who are presenting with occipital neuralgia, doing a nerve block is a great idea. Local nerve blocks are recommended. There are certainly, for the interventional folks in the room, the opportunity to do guided blocks closer to the nerve root level, but yeah, those are all on the table. For some refractory cases, Botox is on the table. You have to meet the criteria for Botox anyway, which is greater than 15 headache days a month, but I have gotten Botox approved for people with refractory migraines type post-traumatic headache. Great. Okay, let's move on to the next section. All right, so next I want to talk about mood, and I just want to give a big shout out to Ginger Polich, who's one of my colleagues who put a lot of these slides together. So mood changes are something that can occur early in concussion, and for most people they are, you know, as we see here on the left, like a normal response to a stressful situation, or there's just some adjustment to not being able to do all the things you normally want to do, school, work, sports, whatever it may be, but over time some people can develop what is starting to look like more of a true mood disorder, whether that's depression or anxiety, specific phobia, perhaps related to a trauma that caused the head injury, PTSD, or anxiety about illness, which we see very commonly in concussion, where people are very worried about the fact that they've in some way damaged or injured their head. So you can sort of get a variety of things, and you just need to keep these various sort of levels or categories of mood changes on your radar when dealing with these patients. So again, in the beginning, medication is not the go-to, so watchful waiting to see if people's mood improves, psychoeducation about concussion, I cannot stress that enough how important it is just to educate your patients about this injury, it will make them feel better, supporting them in their symptoms, excuse me, and then tackling other things like sleep hygiene, exercise, pain will also help their mood, but if that's not helping and people are moving into a chronic phase of mood difficulty after a concussion, thinking about psychotherapy is always an excellent option, and then for those who either have severe symptoms or who are still refractory, we may start thinking about adding medication. There are a lot of different medications on the market, I'm not a psychiatrist, but I'll tell you in our neck of the woods here in Boston, which I consider to be, to have a lot of doctors, it's still hard to get your patients into a mental health clinic, and so I've taken to starting to prescribe these types of medications in patients that I feel are generally low risk, so you might consider doing this in your own practice at some time, depending on where you are, your access to mental health care, and your comfort level with these medications, if you have patients who are high risk, you want to refer to psychiatry, and you certainly shouldn't be afraid to get their input, they're really the experts on a lot of these drugs, but we'll talk about them in reference to mild TBI, so how do you select a medication, you want to target symptoms, so you need to find out what the mood-related symptoms are, you need to think about side effects, you need to think about drug interactions, and then we'll look a little bit at what some of the data has showed us, which might be helpful in mild TBI. Why not just treat everybody? So you wanna think about the fact that it could be ineffective, and we'll talk about that. These medications do have side effects. It can sometimes be challenging to wean people off of them, and that has to be just a consideration. And there are certainly for some of these drugs, not gonna be inexpensive. So here's sort of your mainstays of treatments. You can divide them into groups, or your SSRIs, your SNRIs, tricyclics, and then sort of your miscellaneous drugs. Anything that has an asterisk next to it, there's been some studies on using them in MTBI. So I just denoted that here. Here's a couple of studies. Again, this is in no way exhaustive, so it's not meant to be everything. I think the big thing to take away from this is that trials of using SSRIs and SNRIs for post-TBI depression are small or open-label. There have been two negative double-blind placebo-controlled RCTs for sertraline, and again, not showing significant benefit. Over placebo, although there are a lot of reasons that could be, it may not be that these drugs are not effective, but that placebo may be equally effective. And it also may be that the kind of patients that we're recruiting into these studies. So if you're looking at just mild TBI, none of these studies are only mild TBI. Some of them have moderate TBI patients. Others are mild, moderate, and severe, right? So it's a little hard to sort out exactly why studies have been mixed on using these medications in post-TBI depression. So I'll just throw that out there. You can look through some of these if you'd like. I still would absolutely advocate for using SSRIs and SNRIs in post-TBI depression in terms of which ones you can see here. Sertraline, fluoxetine, and citalopram have all been looked at more than others on the market. And so oftentimes we look at starting with those sorts of medications. When you think about selection of medication, and again, some of you might defer this to your psychiatry colleagues. Others of you will feel comfortable thinking about this in your practice. Some SSRIs can be more activating than others. So for example, fluoxetine may be a little bit more activating. So when somebody who's having more depressive-type symptoms that are less active, you may think about that. Whereas things like S-citalopram, things like paroxetine may be better for your patients who have more anxious-type features. So keep that in mind. Your SNRIs may also be helpful in pain-related concerns. So you may get some added benefit if you wanna think about using an SNRI for either headache, because they are indicated in headache, or for musculoskeletal pain that may be part of the overall trauma. There's some dosing instructions here. Again, these dosing instructions are mostly based on these medications being used outside of TBI. You may consider starting low and going slow when using these medications. Side effects. So lots of patients will discontinue the use of an SSRI or SNRI because of side effects. Very early on, you wanna educate your patients that there could be a little nausea, headache, or particularly for those medications that have an activating effect, a little bit of anxiety. And then as time goes on, people will complain of things like sexual dysfunction, weight gain. There is some low but concern about bleeding risk, but in a otherwise healthy person, that is less of a concern. But again, you just need to educate people on these. You need to ask them about them, and you need to understand if they're being compliant. You know, a lot of patients don't wanna tell us if they're non-compliant. So it's our job to ask in a non-judgmental way because medications are only as good as if the patients are taking them and taking them as they're prescribed. TCAs, so again, we use these mostly for headaches. There are some small studies about their use, again, in general TBI, not limited to MTBI for mood. You need to get up into larger doses to hopefully get the mood-related benefits. There is some side effects that you wanna just be aware of. So TCAs are anticholinergic, right? So you wanna think about sedating-related effects. You wanna think about, this is more so in mod severe TBI, but urinary retention. You wanna think about the antihistaminic effects. Cardiac arrhythmias can occur with using TCAs, not in all patient populations, but in some you might consider getting an EKG prior to starting a TCA. There is some evidence about lowering seizure threshold, although not conclusive. And again, our mild TBI patients, they have not been instrumented, right? Usually they don't have blood on the brain. So their risk for seizures is certainly much lower than our mod severe patients. Here's a list of sort of other antidepressants. And I'll just highlight a few pearls about them. So bupropion, so some of the times that bupropion might be helpful, again, is if you're looking at a mood issue, but also, and I don't have it listed here, but bupropion may also help with cognitive difficulties. It's indicated in ADHD for attention disorders. So sometimes I'll think about prescribing bupropion. Trazodone, we tend to see it more used for sleep, but it does have serotonergic properties. Things like amphetamine salts and methylphenidate, which we're gonna discuss in the next section, are adjuncts for treating primary depression. They're activating, and we'll see a little data that they do help some depression inventories in people with MTBI and concussion. Other drugs, mortazapine, buspirone, can be tried. You just need to be aware of the side effect profiles. These probably won't be your go-to first medications, but just be aware of them. A note on a common side effect to think about in treating mood, so serotonin syndrome, we all heard of this, but bear it in mind. So this is, I think most often people are at risk of this when they're on multiple medications, although it could occur with just being on one serotonergic drug. But if you're combining SSRIs or SNRIs with a TCA or with maybe trazodone for sleep, this is when you might start to get concerned about something like serotonin syndrome. So symptoms can be anxiety, delirium, restlessness. People can complain of some autonomic changes, sweating, warmth, high blood pressure, nausea. And then there are neuromuscular features, so tremors and rigidity. Anecdotally, our concussion patients can have lots of different symptoms around their mental status. They can complain of some autonomic changes, feeling change in temperature or racing heart. And so you have to be thinking about serotonin syndrome because patients may be complaining of these symptoms. You may attribute it to the head injury, and in fact, it might be a medication side effect. So keep this in the back of your mind and always be looking at your medication lists, particularly if you're prescribing multiple agents that can have serotonergic effects. Using antidepressants. So you always wanna try to get patients to engage in a course that's adequate for getting the desired effect, right? So I always remind patients these are gonna take a while to ramp up in their system. They're not gonna feel better right away. And so they shouldn't give up on it. Some will be faster acting than others, but really eight to 12-week trials really needed before you can say that somebody has failed their use. Similarly, if you have patients who are stopping antidepressants, they may say, well, I stopped it, and that wasn't the cause of the change. Well, remember that that medication is gonna be floating around in their system for quite a while. And so they may not see the negative impact of stopping the medication for some time. If you do end up putting somebody on a medication like serotonin, if you do end up putting somebody on a medication like this to help treat their mood after a mild TBI, I usually recommend that they stay on the medication for six to 12 months. Even if they're feeling completely back to normal in all facets of their life, I try to have them stay on it a while. I'm usually getting, if they're staying on a medication like this for this long, they're usually in co-occurring cognitive behavioral therapy or some sort of psychotherapy that's also helping to augment their mood and give them coping strategies. And then you can think about discontinuing it. So when I approach this with my patients, they'll sometimes say, well, how long do I have to take this medicine for? Say, well, if it works, we try it for six to 12 months, and then we try coming off of it and see how you feel. Timing of discontinuing these medications is important. So if you're in pediatrics or you work with adolescents, you might think of weaning these medications during the summertime when kids are less stressed out. For adults, you might think of weaning these medications when their work is not as demanding, just in case they are feeling unwell when they come off or they have a resurgence in their symptoms. It's not during an otherwise stressful time in their life. If patients are improving, things to think about as we discuss compliance, always consider substance use and be asking about that. Are they on the right dose? Do you need to switch medications? Do you need to augment the medications? And again, adding a second psychotropic drug may be a time that you think about getting psychiatry or psychopharmacology involved, unless you really have developed a comfort with these medications. Think about if you're combining these medications with other drugs to treat other symptoms that they could be working against one another. And always feel free to consult psychiatry. Dual medication use. So remember, sometimes you can kill two birds with one stone. So some of these medications will also help with things like insomnia. Some may help with changes in weight. Some may help with inattention or fatigue. And some may also be good for emotional lability or irritability. So bear that in mind. Okay, I'm gonna stop there and we'll take maybe one or two questions about psychopharm if there are any. All right, we do have a couple of questions. One is for the washout period, for the washout period after the six-week washout, any good options to use during that washout period? For, I think that was on a slide about headache. It was, I'm sorry. Okay. So your pro, so in, just going back to medication overuse, usually the culprit is gonna be your short-acting analgesics. So I will put people on prophylactic agents at that time. So that's usually what I'm using. I'm almost always thinking about starting a prophylactic agent in those folks because they're gonna struggle and they clearly are having poorly controlled headaches. That's why they're taking medication around the clock. Thank you. And one more question. Bupropion after a TBI, there's talk about maybe a waiting period due to concern for seizures. Is that something that you're concerned about? Yeah, so any drugs that are gonna increase the, or lower the seizure threshold, you have to be cognizant of in TBI in general. For mild TBI, so the concussed individual who has no, these are uncomplicated mild TBIs, we'll call them, right? No skull fractures, no blood on the brain. We're less concerned about these people having seizures. I think there's a caveat there. You can get the rare case where patients have an impact seizure or, yeah, I can think of some other more unusual cases, but in your sort of run-of-the-mill, straight-down-the-middle concussion patient, their risk for seizure is very low. And probably close to, maybe not exactly, but close to the general population. So, but in your mod-severe patients, your patients who have been instrumented, those who have visible intracranial pathology on CT, so some focus that could generate a seizure, you certainly wanna think about that. Thank you very much. I think we're all set for the next section. Okay, lastly, and we're gonna blaze through this, is how to treat cognitive complaints, which lots of patients who are experiencing ongoing persistent concussive symptoms, or some people term this the post-concussive syndrome, often cognitive complaints are on the list. I, this is my super dumbed-down version of how I conceptualize cognition. So I will present it to you. And again, it is very, very simplified. So cognition is a highly complex entity that many people spend their whole career on. So I am, I'm oversimplifying it, but for the sake of this presentation, I hope you'll bear with me, and I apologize. So when I talk to my patients about their cognition, I think first that they say to me, oh, I can't remember this, I can't remember that, I can't engage here or there. So people have to be able to attend to things, right? So they have to be able to pay attention in the moment to what they're being told. And then if they can pay attention in the moment, they are able to commit things to short-term memory, and hopefully then encode them for long-term memory. And then from there, on top of that, the more complex task is things like executive function, working memory, those sorts of things. So that's, again, my super dumbed-down version of cognition. But I like to put attention at the bottom because I think a lot of people will come to you with a memory complaint. I can't remember things. And when you dig deeper, you find that they're not, that they're having trouble for whatever reason paying attention when the particular conversation is occurring, or when they're, where did they put their keys? Well, were they paying attention at the time when they put their keys down, for example? So again, cognition is not treated with medication right away. Other things you might consider trying, psycho-ed, appropriate expectation setting, right? You're gonna feel maybe a little bit cognitively slow, but this will get better over time. Environmental modifications, again, helping people to remove distractions, chunking out their homework for kids, having adults remove distractions in the workplace. And then certainly cognitive rehabilitation is a great tool for cognitive difficulties. In terms of treating cognitive difficulties with medication, the thing that you can treat best with medication is attention difficulties. So when people complain of memory problems or other sorts of things, it can be more challenging to target them with medication and have success. But attention is an area that we may have some success with medication. I wrote a little review about this a few years back if you wanna look at it, and then a shout out to Amanda Rabinowitz, who just, I saw her and Dr. Watanabe published another review of neurocognition and medication in MTBI, if you wanna look that up, Journal of Head Trauma Rehabilitation recently. But attention, I think, is the best thing you can target. And the main drug that's probably best to target attention is methylphenidate. It's the most widely used across TBI studies, and in MTBI, it has the most data. And remember that methylphenidate is a stimulant, okay? It's a controlled substance. It's gonna inhibit your catecholamine reuptake, so it has dopaminergic, and it acts on dopamine and norepinephrine receptors, and it has weak serotonergic properties. It modulates attention function and, to some extent, executive function, although, again, attention is your main feature. There are a number of small studies of the use of stimulants in mild TBI. I am just, again, this is not exhaustive. I'm just highlighting a few, and I'll have a chart with a few more. One interesting study, for those of you who may deal with military service members or veterans or in the VA, is around using methylphenidate to augment cognitive symptoms in veterans. So I work with the veteran population, and we always get worried about people co-occurring anxiety disorders, PTSD, giving them stimulants, but actually, in the chronic phases of mild TBI, not only have stimulants been shown to help cognitive complaints and attention measures, but they did help on depression measures and some PTSD measures. So while you need to use these medications judiciously in patients that have anxiety disorders, as they can flare anxiety, they may also be helpful. So bear that in mind. There are a couple other studies looking at methylphenidate, and I know this is small, but you can always blow it up on your screen. In mild TBI, again, where you're seeing the best benefit is in attention, maybe a little bit in depression, and in fatigue-related symptoms. And we did this review. We were also looking at ADHD, which I think there's a lot of co-occurring attention deficit disorder, particularly in pediatric populations. And so if you have somebody with co-occurring baseline ADHD who's having an attention problem after their concussion, you may think about things like methylphenidate, not only to try to treat the cognitive symptoms of concussion, but to treat the primary attention disorder. Here's a few more studies. This was a series of work done by Joe Hanson and colleagues looking at the use of methylphenidate. And again, it had its best effect for things like mood and fatigue. And they did an ultimate look at it for cognitive function where it did less well than just simply treating fatigue and mood. A note on amphetamine salts. So while methylphenidate has been studied best, amphetamine salts may be an option in MTBI patients. When I speak to my psychiatry colleagues who use a lot of stimulant medications about whether to trial something like methylphenidate or amphetamine salt for attention, I get a little bit of the tomato-tomato response. Seems to be that we expect amphetamine salts to act similarly to methylphenidate. So again, I tend to go with methylphenidate as a first trial for attention difficulties. And if it doesn't work or people have some poor reaction, I'll try an amphetamine salt instead. A word on amantadine. Amantadine is a drug that we commonly use for arousal in patients with moderate and severe TBI. And it's been trialed in mood and other things around TBI, but we don't have really good data on amantadine for MTBI. I'll tell you again, anecdotally, do I use it in my practice? Yes, sometimes, but I tend to opt for stimulants if there's no contraindication to them over amantadine. Again, that's my practice. And there are a few papers, if you look up pharmacology and concussion, that actually look at how people practice and what people tend to use. And one, I think, came out of the Pediatric Concussion Consortium Group and people tended to opt for methylphenidate over amantadine for what that's worth to the group. The exact mechanism of action is not known for amantadine and why it might help concussion patients. And again, we usually target it in DOC patients. Couple studies here on amantadine for mild TBI. And again, the improvements were modest at best, but I'll leave that. You'll have that so you can read through it. So to sum this all up, and then I'll take questions. Data, we don't have great data on pharmacotherapy and concussion. We use it, most of us are allopathic practitioners, so we're comfortable using pharmacology to try to help patients. And we should use it when symptoms are severe or when patients are refractory to non-pharmacological interventions. We usually are just drawing on inferences from other diagnoses where these drugs are used. We don't understand the dosing well. I think lots of people who treat mild TBI will tell you that patients, for whatever reason, tend to be sensitive to drugs or their side effects and so for that reason, as a mantra, we start at a low dose and we tend to titrate up slowly. Off-label use of drugs, which again, is almost all drugs we discussed here today, is not unreasonable, but it should always be used in conjunction with, again, environmental behavioral changes and all your other rehabilitation services, your PT, OT, speech, et cetera. So that is it for me. I'm happy to take any final questions and again, if anything I said was unclear or if you have any comments, happy to field questions via email or through Sterling. So thanks for having me. I think this is a great, great undertaking by AAP and by Sterling and the group and I wish you all well and I hope you stay safe during this really unprecedented and really unusual time. So thank you. Sorry having some technical difficulties over here. I think we're No, probably doing a great job My screen decided to go nuts Okay Well still having some technical difficulties. All right, I'll hang for a little bit too if if others can hang and You know and since we're at the end if anybody wants to you know brave putting on video or Audio and we'll filter through sterling for now Okay, can you see my screen? Okay Yes. Okay. We weren't getting any questions right there at the end But again, I wanted to have an opportunity for anybody that that does have questions or any that came up that they weren't able to express Please reach out to us on Twitter via email anything and Then there will be daily updates to the schedule and passwords sent out on this website. So that's through the AAP website via webinars so Please check that daily. I anticipate that people will be added daily and I imagine things will come up and we'll have to change So so check it out and these should be at the same time every day. So that's noon Eastern And reach out again, thank you very much for to dr. I Carino appreciate it This was fantastic getting a lot of positive feedback already And please if you are in a program and recognize that some of your folks are missing Please reach out invite them if you see other programs that aren't here Please invite them the idea again is to supplement what you already have and help us bridge through this kind of Logistically difficult time. So again, thank you to dr. I Carino and Thank you to all our participants
Video Summary
The video summary discusses the use of medication in the treatment of mild traumatic brain injury (TBI). The speaker, Alexis Icarino, presents information on the off-label use of medication for the physical, emotional, and cognitive symptoms associated with mild TBI. Attention is given to the prevalence of mild TBI and the importance of behavioral and environmental adaptations as the mainstay of treatment. The speaker highlights the lack of evidence-based pharmacotherapies for mild TBI and emphasizes the use of medication for symptom management rather than a cure. Medications such as analgesics, triptans, tricyclic antidepressants, SSRIs, SNRIs, and stimulants are discussed in relation to specific symptoms and conditions. The speaker also addresses side effects, dosing, and the need for adequate trials of medication before determining efficacy. The use of medication in conjunction with psychotherapy and cognitive rehabilitation is emphasized. The summary concludes by encouraging further research and collaboration in the field of pharmacotherapy for mild TBI.
Keywords
medication
mild traumatic brain injury
off-label use
symptom management
analgesics
triptans
SSRIs
stimulants
cognitive rehabilitation
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