Does Guanfacine Cause Hallucinations in Children?

Abstract

is a centrally acting antihypertensive agent with alpha-2 adrenergic receptor agonist properties. Several open reports noted beneficial effects of guanfacine in treating symptoms of attention deficit hyperactivity disorder (Hunt et al. 1995;Chappell et al. 1995). Side effects commonly reported with guanfacine include dry mouth, somnolence, fatigue, constipation, asthenia, dizziness, headache, and insomnia (Physicians' Desk Reference 1999). Recently, there was a case report of symptoms resembling a manic episode in five children on guanfacine (Horrigan and Barnhill 1998). To date, psychotic symptoms associated with guanfacine use in children have not been reported. The following case describes a youngster who developed visual hallucinations on treatment with guanfacine.A 10-year-old African-American boy was admitted to the psychiatric service for fighting and disruptive behavior. He had a diagnosis of attention deficit hyperactivity disorder and conduct disorder for which he had been treated with 45 mg/day of dextroamphetamine in divided doses for 6 weeks. Prior to hospitalization, he had been partially compliant with his medication. Oral dextroamphetamine 20 mg at 9 a.m., 15 mg at noon, and 10 mg at 4 p.m. was started on admission. On the third night on this dose, he woke up fearful, complaining of visual hallucinations of snakes and frogs crawling everywhere in his room. The hallucinations persisted during the day and at night while he was awake. Dextroamphetamine was discontinued, and his visual hallucinations stopped within 48 h except for one brief hypnopompic event of seeing snakes, 4 days later. The patient was rechallenged with dextroamphetamine 5 mg at noon 1 week later, and he reported hypnopompic hallucinations after snakes and frogs for two successive nights. There were no further reports of hallucinations after stopping the dextroamphetamine.The patient remained hyperactive and disruptive and was started on guanfacine 0.5 mg/day. The dose was gradually increased over the next 2 weeks without difficulties. Two nights after the dose was increased to 2 mg/day, the patient woke up with visual hallucinations of snakes and frogs. He did not respond to reassurance by the staff and was awake the remainder of the night. No visual hallucinations were reported in the daytime. Due to decrease in his blood pressure, the patient was given 1.0-1.5 mg of guanfacine daily over the next 2 days and was free of hallucinations. The daily dose of guanfacine was increased to 2.5 mg, and the patient again complained of visual hallucinations of snakes at night; he was visibly afraid but fell asleep a couple of hours later with no more report of hallucinations. Due to decrease in blood pressure over the next 3 days, the patient was given 1.0-1.5 mg of guanfacine daily and reported no hallucinations. Subsequently, the daily dose of guanfacine was gradually increased to 3.0 mg, and the patient was able to tolerate it without any adverse effects. There was no report of hallucinations on this dose for the remaining 3 weeks of hosp...

Practitioner Review: Current best practice in the management of adverse events during treatment with ADHD medications in children and adolescents

“…Psychotic symptoms: Besides sparse case reports (Boreman & Arnold, 2003; Luthra, Markov, & Ambrosini, 1999), we are not aware of studies specifically and systematically assessing psychotic symptoms in individuals with ADHD treated with guanfacine.…”

Hallucinations Associated With Initiation of Guanfacine

“…There has been only one other report in the literature of hallucinations associated with guanfacine (Luthra et al, 1999), in which a patient developed visual hallucinations after initiation of dextroamphetamine and guanfacine. Symptoms of hallucinations have been reported with other α-adrenergic agonists such as clonidine (Cantwell et al, 1997).…”

Psychosis Associated With Guanfacine

“…One case involved a 10-year-old African American boy who developed visual hallucinations of frogs and snakes in the middle of the night after initiation of both dextroamphetamine and guanfacine. 1 Another case involved a girl taking clonidine and dextroamphetamine, who developed hallucinations after missing a dose of clonidine. 2 Both of these cases involved concomitant use of psychostimulants, which are known to be potential hallucinogens.…”

“…There has also been speculation that the visual hallucinations, in particular, may be a form of hypnopompic hallucinations, deriving from rebound hyperarousal in the middle of the night. 1 All 4 of these pediatric case reports are characterized by acute onset after initiation or recent dose increase, duration of symptoms which is curtailed by discontinuation of the medication, and a complete return to premorbid functioning. One of the case reports noted that it is unclear whether symptoms would have resolved even if the α-agonist had been continued.…”

“…One of the case reports noted that it is unclear whether symptoms would have resolved even if the α-agonist had been continued. 1 Although admittedly rare, it is important that psychotic symptoms be considered as a potential adverse effect, particularly given that α-agonist medications seem to be prescribed more regularly now. Of note, previous case reports involved polypharmacy, whereas in this case, the patient was not on any other psychopharmacologic agents.…”