Paulo Emidio Lobão Cunha

Hello. - I'm sorry. Thank you. Thank you. Sorry, I think my brain is a black person, and it's a black person, and it's a black person, I'm pressing it several times. Well, with regards to the medicals that you passed, all of them were cited in the presentation as treatments that have a approval, that have a... I don't know necessarily the approval. is expressed for the TEA, as for example, as a respiratory problem for the ZOLTEN, since 2006 and 2009 respectively, in FDA. but that has evidence that supports your clinical prescription. So first you said that the fluoxetina is a inhibitor seletive of recapturing serotonina. It's a drug that is very used for treatment of depressive and anxiety. Many times, not necessarily, we will have these symptoms established in the patient. So we will end up treating many behaviors that are linked to this disorder without necessarily closing criteria for them, but that in contrapartida are the behaviors that are affecting significantly the individual. So we think that, of course, all the part of our treatment, he also thinks about us in mitigating the behaviors that are affecting the patient and the factors that are going to be able to modify them. But, many times, there are situations that are out of our control. So we can adapt to schools, we can do schools that have support of sensory rooms in the same school, where the patient has a curricular adapt, which doesn't necessarily have to do 10 tasks in sequence, he will have to do 2, he will have space to be able to rest, to be able to stay in the classroom, to be able to return to the school. But the big problem is that, many times, it's not out of our control, and we also have to think that, We will not be able to to modify all the environment for that individual. We need to, as a society, have adaptations, with sure. We are very close to society in this sense, but in any way, we have to think individually. Well, this child, unfortunately, has a lot of depressive behaviors that are It's difficult to deal with other people. Because there is a moment when a child starts to develop an autocratic, that she starts to perceive the difficulties. and especially women who have a higher cognitive power because they end compensating many times with the phenomenon of mascaration. And then, we can even It's very angustiante for her, very cansative. The whole time she has to be able to do social adaptations that she wouldn't be able to do. So, this really creates a behavior I'm very anxious, depressed, and many times the medicine helps a lot. It's a medicine that has a few effects adversely, the most common is related to the apetite. Some of the children can feel a gastrointestinal or a tonture in the beginning of the treatment, but in general I have positive experiences with it, with the fluxetina. when it is very well-indicated. The second medicine you said was the metilfenidato. The metilfenidato is the first line treatment for the CT-100 imperatividade, not TDAH. It is a medicine that is psicoestimulant, so it will be increased the levels of dopamine and noradrenaline, especially in the front, but not only in it. It's a very important thing to do with the patient's treatment, to have a mental health, and to have a mental health. relatively satisfying, we opt for concentrating it because, for some reason, he can be having a difficulty in concentration, which is often more accentuated in the patient with TEA, because he will not only deal with TDAH, he will deal with also with social difficulties that difficult the attention of this child in collective environment, especially those who are in school, in school, in school, in school, in regular. And the third thing you said was... I forgot. Clonidina? It was the Aripiprazol. The Aripiprazol and Esperidone are the same class. They are the same type of antipsicóticos, they are the most common use in the TEA, because they have a specific approach for a transtorno, for a treatment of irritability, for a agressiveness, for a treatment related to... uh... There's a difficulty, even for a certain control of the stereotipias, for some comportments of the object. And when I say that, many times the parents can say, "my son is not aggressive and so much." It's not necessarily for this. It's necessarily for that child who has a humor irritable, that child who can't regulate well. That child who, unfortunately, we have to think that the impact that we have to do for a lot of suffering, for that child, will cause. the significance of these behaviors. There are, yes, effects adversely that are not desired, but we have to monitor them, like, for example, the gain of weight, the patient increases the appetite, There are some patients, including, that, especially in the treatment, that feel a lot of sonolence. So, many times we have difficulty, as we can progress, if we can use of some dose diurnal. And, also, at the same time, I think, in my opinion, that the most challenge is not necessarily the treatment in itself, and the posology. These are the indications. The most difficult thing I see today, I even said this last time I was here, especially in the field of SUS, It's not easy to get it. It's not easy to get it. So, for example, I particularly in a turn, I attend three patients, four at the maximum. And, sometimes, it's a segment that I do in a segment. One first, I do in four different days. To be able to get a piece of the individual, because the big problem is... It's very complex because we have to think about who is dealing with people that they don't necessarily will do an auto-analyze and do it. So, we have to take data of the pais, which, many times, can also have a diagnosis. And I think that sometimes even the same person has difficulty with the affective involvement. If I was talking about my son, for example, I would say something different than what a professor would say. So we have to think that we can only involve the field of the domestic, we have to enter the school environment. So I think that when we think about a therapy like this, a therapy plan like this, I think that the first point is: pensar que é um transtorno que tem uma alta prevalência, então não dá para ficar na mão de subespecialistas, neurologistas infantis ou psiquiatras infantis. A gente tem que pensar no âmbito de SUS, numa capacitação que vai desde a atenção básica, para a gente poder realmente seguir o sistema de referência e contra-referência. Claro que com a decisão terapêutica medicamentosa, até, por exemplo, no primeiro caso que você citou, que são três medicamentos no mesmo paciente, medicamentos, inclusive, se a gente for pensar do ponto de vista de ação, with the other, they end up getting rid of it. But of course there is a technical indication, to be able to be prescribed for the individual with dose specific. So I understand that it is a speciality of the fact. But at the same time, for a lot of people to have a class with a clinical clinical class and that they don't have a diagnostic and that they don't have access to anything. And at the same time, it's not just that. We also have to think about it. there will be a therapist for everyone. So we have to think about centers that will be able to be able to be co-terapeutas. Not that the parents will be able to be doing therapy at home, but that will help in rehabilitation, because, in the end of the day, the product is the communication and interaction of these individuals in social media. So, it doesn't work to think that, trancated in a room of 6 square meters, this child will learn habilidades. Dr. Paulo, thank you very much.

Primeiramente, acho que talvez a nossa maior dificuldade com algumas formulações que não são disponíveis em xaropes ou em gotas. que são somente comprimidos. Então, quando a gente trabalha com faixa etária pediátrica, muitas vezes a gente tem dificuldade de conseguir... que a criança tome o medicamento. Então, por exemplo, a clonidina é um exemplo deles, né? Que a tensina, que só tem comprimido. Até o próprio metilfenidato também, que a gente macera comprimido. Então, abre a cápsula do... da forma L.A. mas de qualquer sorte também o medicamento que não tem formulação líquida como tem fora do país, inclusive nos Estados Unidos, por exemplo, em 2018 eu fiz um estágio de treinamento na área de tração e desenvolvimento lá, E... Até em forma de chiclete ele tem a formulação do metifinidato. Então é impressionante a questão relacionada ao ponto de vista de formas de administração, que a gente tem um pouco de dificuldade. Agora, com relação a medicamento que a gente não tem aqui... Por exemplo, a guanfacina é um que faz muita falta pra gente. Porque a guanfacina, ele é um medicamento que... Quando a gente tem pacientes com transtorno de desatenção, principalmente com pacientes que com o TEA, que é o nosso foco, comórbidos, e que a gente não tem condição de utilizar psicoestimulantes, eles seriam um excelente... medicamento para a gente poder utilizar em substituição, mas infelizmente a gente não tem comercialização no Brasil. E tem maneiras de exportar, mas ela não é fácil e ao mesmo tempo também ela não é tão acessível. então não é algo que dá pra pensar do que em termos de população em geral. Obrigado. Obrigada, doutor Paulo.