Medications for pediatric obsessive-compulsive disorder

Agent	Initial daily dose	Suggested dose titration based upon response	Maintenance daily dose range	Selected characteristics*
SSRIs*
Fluoxetine^¶	Children: 5 to 10 mg Adolescents: 10 to 20 mg	Increase daily dose by 5 to 10 mg (child) or 10 to 20 mg (adolescent) after 14 days or more	Pre-adolescent: 20 to 30 mg Adolescent: 20 to 60 mg	Prolonged half-life Metabolized by and inhibits CYP2D6
Fluvoxamine^¶	Children: 12.5 to 25 mg Adolescents: 25 to 50 mg	Increase daily dose by 25 mg (child) or 25 to 50 mg (adolescent) after 7 days or more	Pre-adolescent: 50 to 200 mg Adolescent: 50 to 300 mg	Girls generally require lower maintenance doses than boys Give in divided doses with meals and bedtime to minimize side effects Metabolized by CYP1A2 and 2D6 Inhibits CYP1A2 and 2C19
Sertraline^¶	Children: 12.5 to 25 mg Adolescents: 25 to 50 mg	Increase daily dose by 25 (child) or 50 mg (adolescent) after 7 days or more	25 to 200 mg	Diarrhea more frequent than other SSRIs Metabolized by CYP2D6 Inhibits CYP2D6 with larger doses
SSRI - potential alternate*
Paroxetine	Children age ≥7 years: 5 mg Adolescents: 10 mg	Increase daily dose by 10 mg after 7 to 14 days or more	10 to 60 mg	Short half-life Mild anticholinergic side effects Metabolized by and inhibits CYP2D6
TCA
Clomipramine^¶	Children ≥10 years and adolescents: 25 mg	Increase daily dose by 25 mg every 7 to 14 days or more	25 to 200 mg Maximum: smaller of 200 mg or 3 mg/kg per day^Δ	Only TCA with demonstrated efficacy in pediatric OCD Cardiovascular screening including ECG recommended prior to initiating treatment Anticholinergic side effects may limit usefulness in children Drowsiness, irritability, and vomiting may be seen Give in divided doses with meals and at bedtime to minimize side effects Metabolized by CYPs 1A2, 2C19, and 3A4
SGAs for SSRI augmentation
Risperidone	0.25 mg	Increase daily dose by 0.25 mg after 7 to 14 days or more	Maximum: 1.5 to 2 mg	Metabolic adverse effects

Clinicians should be aware of the potential for activating side effects of antidepressants in younger children and regulatory warnings of potential for an increased risk of suicidality in children. All doses shown are for oral administration.

SSRI: selective serotonin reuptake inhibitor; TCA: tricyclic antidepressant; OCD: obsessive-compulsive disorder; ECG: electrocardiogram; SGA: second-generation antipsychotic.

* Common generally mild adverse effects of SSRIs seen in children treated for various anxiety disorders may include headache, anorexia, vomiting, sleep disturbance, and somnolence.

¶ Sertraline, fluoxetine, and fluvoxamine are approved for treatment of OCD in children age ≥6, 7, and 8 years respectively in the United States. Clomipramine is approved for treatment of OCD in children age ≥10 years in the United States.

Δ Dose-related ECG changes have been reported in children and close monitoring is necessary with larger doses. According to the product information approved in the United States, doses >2.5 mg/kg per day are not recommended in children.

Courtesy of authors with additional data from:

Katzman MA, Bleau P, Blier P, et al. Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive-compulsive disorders. BMC Psychiatry 2014; 14:S1.
Rynn M, Puliafico A, Heleniak C, et al. Advances in pharmacotherapy for pediatric anxiety disorders. Depress Anxiety 2011; 28:76.
Martin A, Scahill L, Kratochvil C. Pediatric Psychopharmacology, Oxford University Press, New York 2010. p.480.

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Medications for pediatric obsessive-compulsive disorder