Lurie Center Experts Provide Guidelines to Help General Practitioners Provide Pharmacological Treatment of Patients with Autism

Christopher J. McDougle, MD, Director of the Lurie Center for Autism at Mass General for Children, is senior author of new guidelines published in BMC Medicine, Pharmacological Treatment in Autism: A Proposal for Guidelines on Common Co-Occurring Psychiatric Symptoms.

Q: Why Did You Create These New Guidelines?

The escalating prevalence of autism spectrum disorder (ASD) in recent years has created an urgent need for additional medical providers capable of delivering autism-competent care. Nowhere is the need greater than in managing co-occurring neuropsychiatric conditions.

We wanted to give primary care providers (PCPs) guidelines for the recognition and safe pharmacologic management of common co-occurring psychiatric and behavioral conditions in ASD patients.

While in some cases, the standard of care (SOC) for managing these conditions in ASD patients is comparable to that of non-autistic individuals, there are other cases where the treatment paths differ significantly.

Q: What are the Key Takeaways?

• For sleep disturbances in ASD, initial strategies align with the SOC for non-autistic patients, emphasizing sleep hygiene and melatonin use
• For ASD patients with ADHD, α2-adrenergic agonists can sometimes be more suitable than stimulants
• For ASD patients with anxiety, buspirone and mirtazapine are preferred as first-line compared to selective serotonin reuptake inhibitors (SSRIs) for patients without autism
• For ASD patients with depression, duloxetine, mirtazapine, bupropion, and vortioxetine are recommended ahead of SSRIs
• For irritability, guanfacine, risperidone, or aripiprazole may be appropriate, depending on severity.

Q: What are the Key Principles for Effective Pharmacological Treatment of Patients with ASD?

The risk/benefit ratio of pharmacological treatment of co-occurring psychiatric symptoms in those with ASD can be greatly enhanced according to the following principles, McDougle and team write:

• Start Low and Go Slow: Begin treatment at the lowest practical dose and gradually work upward
• Monitoring Matters: Make regular assessments to ensure the medication remains necessary and is still having the desired effect
• One Size Does Not Fit All: Approaches that account for individual patient needs have the greatest potential for patient compliance and satisfaction, leading to better treatment outcomes
• Back to the Basics: Pay attention to sudden changes in a patient’s behavior may signify basic healthcare issues that have been overlooked

Q: What is Your Hope for these Guidelines?

The number of ASD patients in the U.S. far exceeds the capacity of the current subspecialty care model.

General practitioners are both highly capable and willing to fill in this gap in ASD care if given sufficient education and resources to do so.

This manuscript presents relevant, easy-to-reference prescribing guidelines on the treatment of sleep disturbances, ADHD, anxiety, depression, and irritability in ASD, based on expert opinion and combined with current research.

Our hope is that empowering general providers to manage first-line care for patients with ASD and interfering neuropsychiatric symptoms and disorders, will give these patients faster access to competent care and will increase specialist time to provide care to patients with more complex conditions.

Paper Cited: Manter, M. A., Birtwell, K. B., Bath, J., Friedman, N. D. B., Keary, C. J., Neumeyer, A. M., Palumbo, M. L., Thom, R. P., Stonestreet, E., Brooks, H., Dakin, K., Hooker, J. M., & McDougle, C. J. (2025). Pharmacological treatment in autism: a proposal for guidelines on common co-occurring psychiatric symptoms. BMC medicine, 23(1), 11. https://doi.org/10.1186/s12916-024-03814-0