What medication might help a 25-year-old severely autistic female with obesity, severe back pain managed with hydrocodone (hydrocodone), and chronic face-picking behavior?

Medication Options for Face-Picking in a Patient with Autism, Obesity, and Back Pain

For a 25-year-old severely autistic female with obesity, severe back pain, and chronic face-picking behavior, an SSRI such as fluoxetine or sertraline would be the most appropriate first-line medication option, as these medications can help reduce repetitive behaviors while being weight-neutral with long-term use.

Understanding the Clinical Presentation

This patient presents with multiple challenges that need to be addressed:

• Severe autism with repetitive behavior (face-picking)
• Obesity
• Severe back pain requiring occasional hydrocodone
• Previous failure of topical treatments for face-picking

Medication Selection Algorithm

First-Line Options:

1. SSRIs (Selective Serotonin Reuptake Inhibitors)

   • Fluoxetine or sertraline are preferred as they have been associated with weight loss with short-term use and weight neutrality with long-term use 1
   • These medications can help reduce repetitive behaviors common in autism
   • Avoid paroxetine as it has the greatest risk for weight gain among SSRIs 1

2. Antipsychotics with Lower Weight Gain Potential

   • Aripiprazole - FDA-approved for irritability associated with autism in children (though not specifically for adults) and has lower risk for weight gain 1, 2
   • Ziprasidone - Most weight-neutral option in the antipsychotic class 1

Second-Line Options:

1. Topiramate

   • Associated with weight loss 1
   • May help with both impulsive behaviors and pain management
   • Can be used as adjunct therapy

2. Bupropion

   • Only antidepressant consistently shown to promote weight loss 1
   • May help with impulsive behaviors
   • Caution: can be activating and may exacerbate anxiety 1

Important Considerations

Avoid These Medications:

• Olanzapine, clozapine, quetiapine, and risperidone - consistently associated with weight gain 1
• Mirtazapine - associated with significant weight gain 1
• First-generation antihistamines - more potent antihistamines have greater potential for weight gain 1

Opioid Considerations:

• Use caution with opioid medications in patients with autism and pica/picking behaviors
• Case reports document risk of opioid overdose in patients with autism due to altered drug metabolism or absorption 3
• Consider naltrexone as a potential option for patients with "high opioid tone" autism 4, though evidence is limited

Weight Management:

• Any pharmacotherapy for obesity should be considered as adjunct treatment to behavioral interventions 1
• Consider medications that address both behavioral issues and weight management

Monitoring and Follow-up

1. Medication Efficacy

   • Monitor face-picking behavior frequency and severity
   • Assess for improvements in overall functioning and quality of life

2. Side Effect Monitoring

   • Regular weight monitoring
   • Assessment of sedation, metabolic parameters, and other medication-specific side effects

3. Pain Management

   • Reassess back pain management strategy
   • Consider non-opioid alternatives when possible 5

Conclusion

For this 25-year-old severely autistic female with obesity, severe back pain, and chronic face-picking behavior, start with fluoxetine or sertraline as first-line therapy. If inadequate response after 4-6 weeks of optimal dosing, consider adding or switching to aripiprazole or ziprasidone. Topiramate may be considered as an adjunct therapy if weight management becomes a priority alongside behavior management.