Effectiveness of Propranolol for Treating Anxiety and Aggression in Children and Adolescents with Autism Spectrum Disorder

Background:  Autism spectrum disorder (ASD) is a multifactorial disorder, and currently, there are no routinely prescribed medications that can improve core symptoms in patients with ASD (Santosh and Singh, 2016). The current clinical practice is to target the symptoms of co-occurring disorders associated with ASD such as hyperactivity, irritability, anxiety, psychosis, depression, aggression, and/or repetitive behaviour. Anxiety and aggression management is critical in optimising outcomes in at least 40-50% of children and adolescents with ASD. Anecdotal evidence has pointed towards the beneficial effects of the prototypical beta-blocker propranolol for managing the symptoms of anxiety and aggression in children and adolescents with ASD; however, further clinical effectiveness studies are warranted to explore this.

Objectives: To assess clinical effectiveness of propranolol in reducing anxiety and aggressive symptoms in children and adolescents with ASD

Methods: This service evaluation project was approved by the South London & Maudsley NHS Foundation Trust, UK. All children with ASD treated in the Centre for Interventional Paediatric Psychopharmacology and Rare Diseases (CIPPRD), a national specialist service in the United Kingdom that specializes in the psychopharmacological management of complex disorders and rare diseases were screened to identify patients being treated with propranolol. From 180 children within the clinic, 27 were diagnosed with ASD and were prescribed propranolol - 4 of these were discharged from the clinic, resulting in 23 eligible children aged between 8-19 years. Parents and clinicians in the CIPPRD routinely complete a series of web-based questionnaires using the HealthTracker^TMplatform, in order to capture information on clinical effectiveness of treatments used in routine clinical care.

Results:  The mean daily dose of propranolol was 44.67+/-22.31mg and mean duration of use was 24.00+/-12.71 months. The pre- and post-treatment measures on the Profile of Treatment Response (POTR) measuring symptoms and side-effects, Clinical Global Impression scales, and Therapeutic Efficacy Index revealed a significant reduction in ‘anxiety,’ ‘aggression,’ and ‘explosive rage’ with propranolol treatment. The main side-effect was increased appetite. The mean CGI-Improvement scores for propranolol treatment was 1.61+/-0.78 and the Efficacy Index was 3.16+/-1.05, suggesting very good efficacy. The results show that ‘emotional, behavioural, and autonomic dysregulation’ (EBAD), is an important aspect in difficult-to-manage ASD, which responds to treatment with propranolol.

Conclusions: This study provides further supportive evidence for the use of propranolol for managing the symptoms of anxiety and aggression in children and adolescents with ASD. It also shows that beta-blockers can be used when managing EBAD in ASD with previously poor treatment outcomes. Given the current findings, further exploration for the use of propranolol for anxiety and aggression symptoms in children and adolescents with ASD is warranted.