The role of the pharmacist in fetal alcohol spectrum disorder (FASD) involves prevention, counseling, and treatment. Regarding prevention, pharmacists should counsel women of childbearing age on contraception and the risks of alcohol use during pregnancy, as unplanned pregnancies are common and alcohol use is prevalent. When patients report lost or stolen medications, pharmacists should consider non-adherence due to diversion or misuse as well as the complex needs of those with FASD. Treatment of patients with FASD may involve psychostimulants, alpha-2 adrenergic agonists, or other medications to target symptoms like inattention and impulsivity.
7. Alcohol and the developing central
nervous system
Direct toxic effect leading to neural cell death and decreased
brain volume
Impairs transport of glucose and amino acids
Derangement of chemical and hormonal systems controlling
migration and maturation of cells
8. Mechanism of prenatal alcohol brain
damage
Direct cell death: Apoptosis Vs. Necrosis
Reduced cell proliferation (glia cells)
Migration errors in brain development and gene expression
Inhibition of nerve growth factor
Disruption of neurotransmitters
Oxidative stress
9. Oxidative homeostasis is the way the body maintains the balance
between free radical (oxidants) production and antioxidant reserve.
Oxidative stress is the enhancement of the body’s production of
free radicals and other strong oxidants either by increased
production of the radical or by depletion of body stores of
antioxidants.
10. Alcohol and oxidative stress
Certain pathways of alcohol metabolism result in the
generation of ROS.
Alcohol may reduce antioxidant levels. Experimental evidence
suggests that these factors may contribute to alcohol-induced
cell damage and cell death in the fetus
( Guerri 1998; Henderson et al. 1995; Kotch et al. 1995)
14. Why Psychostimulants?
• Described as “questionable”– Infante ‘11
• 50-90% of FASD meet diagnostic criteria for
ADHD –Bhatara et al ‘06; – Freyer et al ’07
• Two crossover control trials –Oesterheld ‘98; Snyder ’97
• Amphetamine preferred to methylphenidate
• Retrospective review evidence – Doig et al ‘08
• 40-79% of FASD on stimulants – Dalen ’09; Frankel ‘06
• Psychostimulants effective in attention deficits,
impulsivity, oppositional, and conduct disordered
symptoms common in FASD
15. Why Alpha-2-Adrenergic Agonist?
Guanfacine & Clonidine
• Significantly decreased fine motor speed -
Connor ’00
• Effective in managing sleep problems - Calles et al
’08
• Facilitate dopamine & norepinephrine
neurotransmission
18. • Who should you
direct your
prevention efforts
to because using
alcohol during
pregnancy is more
likely?
• Low education and low
income
• High education and high
income
• Rural, remote, Aboriginal,
and inner-city
communities
• Adolescent exploring
sexuality
• University student being
treated for STC
19. PREVENTION ROLE
• HAVE A “GOD LENS”
• WOMEN ON
CONTRACEPTION
• Anything to do with sex
• REMEMBER: 50% of
pregnancies are
unplanned and alcohol
use among child
bearing women is high.
20. What comes to mind when a patient
repeatedly comes back saying “my
meds got lost or stolen”?
21. Disappearing acts
• Blaming the dog
• Blaming the child
• Lost in the bus
• Washed away
• Muggers on the loose
• The strongest wind yet
• Border services fault
22. COUNSELLING ROLE
• LOST MEDICATION
• DIVERSION AND
MISUSE
• SIDE EFFECTS
LANGUAGE
• EXPLOITATION BY
OTHERS
• SIMPLIFY DISENSING
• RESPONSIBLE OTHER
• DOSE ESCALATION
23. TAKE HOME POINTS
• For every twenty patients one has FASD
• For every two females at least one needs
prevention counselling
• When “my meds are lost” think of FASD too
• Modify your language to comprehension level
• Simplify dispensing practices
• Initiate projects and research to support
escalating and reducing doses
