Journal Article Annotations
2025, 2nd Quarter

Neuropsychiatry

Annotations by Nathan Praschan, MD, MPH, Laura Duque, MD, Jacob Weiss, MD
July, 2025

Pharmacological Treatment of Autism Spectrum Disorder: A Systematic Review of Treatment Guidelines.

PUBLICATION #1 — Neuropsychiatry

Pharmacological Treatment of Autism Spectrum Disorder: A Systematic Review of Treatment Guidelines.

Sota Tomiyama, Kazunari Yoshida, Hideaki Tani, Hiroyuki Uchida.

Abstract: Pharmacopsychiatry. 2025 May;58(3):100-116. doi: 10.1055/a-2514-4452. Epub 2025 Jan 31.

Currently available systematic reviews on the pharmacological treatment of autism spectrum disorder (ASD) do not encompass all the evidence, as they exclude guidelines issued by national or local authorities that are not indexed in search engines such as PubMed.A systematic literature search was conducted to identify clinical guidelines on this topic using EMBASE, Medline, and PsycINFO. A manual search was also performed to identify guidelines by national or local authorities not included in the aforementioned databases.Thirty-eight guidelines were identified through manual search, including 27 items through search engines, 2 general guidelines, and 9 government agency guidelines. Many guidelines recommended risperidone (N=16) for the characteristic behaviors of ASD core features. For attention-deficit/hyperactivity disorder (ADHD) features, methylphenidate was most frequently recommended (N=23) for both inattention (N=6) and hyperactivity/impulsivity (N=16). Risperidone was also frequently recommended for maladaptive behaviors (N=33).A comprehensive literature search identified treatment guidelines for ASD issued by local or national administrative bodies that were not captured through search engines alone. There was some consensus among the guidelines on the use of psychotropics in alleviating specific features of ASD. However, physicians need to be aware of the lack of high-quality evidence supporting these recommendations

Annotation

The finding:
This systematic review assessed the currently available guidelines for pharmacotherapies in autism spectrum disorder (ASD). The authors identified a total of 38 guidelines. Targeted symptoms and behaviors were categorized into three major groups: core ASD features, attention-deficit/hyperactivity (ADHD) features, and comorbid features (self-injury, irritability/aggression, behavior problems, anxiety, OCD, mood, sleep, catatonic, and/or tics). For the treatment of core features of ASD, 30 medications were included, with the highest number of guidelines recommending risperidone (N=17), followed by aripiprazole (N=11) and fluoxetine (N=5). For ADHD features, the most common medications were methylphenidate (N=23), atomoxetine (N=16), and guanfacine (N=15). For maladaptive behaviors, 49 total medications were included, and risperidone (N=33), aripiprazole (N=26), and haloperidol (N=8) were recommended most frequently.

Strength and weaknesses:
This review’s strengths include adherence to PRISMA guidelines and inclusion of local and national guidelines not indexed in literature databases or included in prior reviews and meta-analyses. However, the pharmacological recommendations from these guidelines were heterogeneous, lacked support from high quality evidence, and features of ASD were not reliably distinguished from common comorbidities (e.g. intellectual disability).

Relevance:
Patients with ASD may experience distressing symptoms or exhibit challenging behaviors that significantly interfere with functioning and pose risks, particularly in the hospital setting. The C-L psychiatrist’s knowledge of effective management strategies and treatment options is crucial for informed care of these patients. While there was relative consensus for very few agents to target features of ASD, this review calls for more rigorous studies that examine the efficacy and safety of pharmacological treatments to inform evidence-based treatment guidelines. The authors highlight the need disseminate these guidelines to a broader clinical and research audience involved in the care of patients with ASD.