title: An International Survey-based Algorithm for the Pharmacologic Treatment of Irritability in Huntington's Disease.
abstract: It is generally believed that treatments are available to manage irritability in Huntington's disease (HD). However, lack of an evidence base prevents the establishment of treatment guidelines for this symptom. The research literature fails to address behavioral intervention strategies, drug selection, drug dosing, management of inadequate response to a single drug, or preferred drugs when additional behavioral symptoms comorbid to irritability are present. In an effort to inform clinical decision-making we surveyed an international group of experts to address these points. The experts consistently endorsed an antipsychotic drug (APD) as first choice for treatment of urgent and aggressive irritability behaviors. However, there was variation in practice patterns for treating less severe symptoms. Serotonin reuptake inhibitors (SSRIs) were first choice drug treatments by most respondents across all geographic regions. However, APDs were also endorsed as first choice for mild or moderate irritability, more frequently in Europe than in North America and Australia. Antiepileptic mood stabilizers (AEDs) were used by fewer respondents as first choice drug. Perceived efficacy for control of mild or moderate irritability was judged somewhat higher for APDs than SSRIs or AEDs. Benzodiazepines were not used as monotherapy, but frequently as an adjunctive drug in the setting of comorbid anxiety. Though many cited lack of experience with mirtazapine, others familiar with its use in HD chose it as an alternative monotherapy, or as adjunctive therapy if insomnia was a comorbid factor. This report presents survey results, reviews available irritability studies, and lastly proposes an algorithm for the treatment of irritability in HD derived from expert preferences obtained through this survey.
authors: Departments of Neurology and Psychiatry, Beth Israel Medical Center, New York, NY;  Department of Psychiatry, Leiden University Medical Centre, Leiden; and Centre for Mental Health Care Delfland, Delft, Netherlands;  Department of Psychiatry and Department of Neurology, University of Maryland, School of Medicine, Baltimore, MD USA;  University of Manchester, Manchester Academic Health Sciences Centre and Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK;  Department of Psychiatry, Duke University Medical Center & North Carolina Center for the Care of Huntington's Disease;  Institute for Systems Biology;  CHDI Foundation, Inc., Princeton, NJ and  Huntington's Disease Drug Works.
authors: Mark
authors: M
authors: Groves
authors: Erik
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authors: van Duijn
authors: Karen
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authors: Anderson
authors: David
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authors: Craufurd
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authors: Edmondson
authors: Nathan
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authors: Goodman
authors: Daniel P
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authors: van Kammen
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authors: Goodman