ADHD
Medicines
Medications
known as stimulants have long been employed in the treatment of Attention
Deficit Hyperactivity Disorder. These medications improve a chemical imbalance
in the brain which is causing the symptoms. A number of neuro-imaging studies
have shown that the brain functioning of ADHD patients does improve and appears
to be more like the normal group after they have taken their prescribed
medication. The
Drug
Digest provides an excellent synopsis on the use of stimulants with children
and adults. For updates on new medications and warning about medications the
FDA website is your best source of
information.
 Medications
usually used to treat ADHD improve the availability in the synapse of two
neurotransmitters, dopamine and norepinephrine. Specific neurotransmitters
(brain chemicals) are necessary to carry a nerve impulse (message) along a
neuropathway (circuit). When a neurotransmitter is not fully available, a
message may be stopped short of its intended destination. When this happens, the
function regulated by that circuit may not work as well as it should.
There has been
concern about the over prescribing of stimulant medications to children. Recent
research shows that the number of prescriptions rose by 30% from 1991 to 1995
with 0.3% and 0.9% of the child population receiving prescriptions in the
respective years. However, with the prevalence of the disorder estimated to be
at 5.0%, one could make a case for under prescribing. Most authorities believe
that stimulants are both over and under prescribed based diagnostic and patient
compliance issues so that some children are receiving medication they do not
need while others are not receiving this necessary treatment for their
condition.
Medications that treat ADHD are not tranquilizers or sedatives. They do not slow
down the nervous system. They actually improve functioning in various areas of
the brain involved with attention, concentration and self-control. Over 200
well
controlled
studies have shown that these medications are the safest and most effective
psychiatric medications. Failure to treat ADHD with medications may result in
increased risk of substance abuse and decreased white matter volumes in the
brain as well as poor academic achievement, low self-esteem, difficulty in a
wide range of social situations, over reaction to change and frustrating
circumstances and less likelihood of success as adults. [See
AAP Treatment Guidelines for further discussion of effectiveness].
Common ADHD
Medications
Eclipse:
Top Ranking ADHD Medications
Attention Deficit Hyperactivity Disorder Medication Prescribing
Practice:
Unlike most other medications,
stimulant dosages usually are not weight dependent. Clinicians should begin with
a low dose of medication and titrate upward because of the marked
individual variability in the dose-response relationship. The first
dose that a child's symptoms respond to may not be the best dose to
improve function. Clinicians should continue to use higher doses
to achieve better responses. This strategy may require
reducing the dose when a higher dose produces side effects or no
further improvement. The best dose of medication for a given child is
the one that leads to optimal effects with minimal side effects. The
dosing schedules vary depending on target outcomes, although no
consistent controlled studies compare different dosing schedules. For
example, if there is a need for relief of symptoms only during
school, a 5-day schedule may be sufficient. By contrast, a need for
relief of symptoms at home and school suggests a 7-day schedule.
According to the AAP Treatment
Guidelines, at least 80% of children will respond to one of the stimulants if
they are tried in a systematic way. Children who fail to show
positive effects or who experience intolerable side effects on one
stimulant medication should be tried on another of the recommended
stimulant medications. Children who fail 2 stimulant medications can be tried
on a third type or formulation of stimulant medication for the same
reason. The next step would be to review the history and symptoms to confirm
the diagnosis. Primary care physicians most likely
will consider referral to a child and adolescent psychiatrist at this point. Bupropion,
tricyclic antidepressants (TCAs), and alpha-agonists are often used in the
treatment of ADHD even though they are not approved by the FDA for this purpose.
Although there is at least
one double blind, randomized controlled trial for
bupropion, TCAs
and Clonidine, the evidence
base for these medications is far weaker than for the FDA-approved agents. [An
article from the
University of Maryland addresses selection of medication for ADHD treatment]
ADHD Medication Side Effects:
Stimulants are generally considered safe
medications, with few contraindications to their use. Side effects occur early
in treatment and tend to be mild and short-lived.Ref
The most common side effects are decreased appetite, stomachache or
headache, delayed sleep onset, jitteriness, or social withdrawal.
Most of these symptoms can be successfully managed through adjustments
in the dosage or schedule of medication. Approximately 15% to
30% of children experience motor tics, most of which are transient,
while on stimulant medications. In addition, approximately half of
children with Tourette syndrome have ADHD. The effects of medication
on tics are unpredictable. The presence of tics before or during
medical management of ADHD is not an absolute contraindication to the
use of stimulant medications.Ref
A review of 7 studies comparing stimulants with placebo or with
other medications indicated no increase in tics in children treated
with stimulants.Ref
Safety Issues Related to ADHD
Medicines:
Patients
treated with medication for ADHD should have their height and weight monitored
throughout treatment. If the patient
has a change in height or weight that crosses 2 percentile lines, this suggests
an aberrant growth trajectory. In these cases, a drug holiday should be
considered, if return of symptoms during weekends or summers does not lead to
marked impairment of functioning. The clinician should also consider switching
the patient to another ADHD medication. It is important for the clinician to
carefully balance the benefits of medication treatment with the risks of small
reductions in height gain, which as of yet have not shown to be related to
reductions in adult height.
FDA Directs ADHD Drug Manufacturers to Notify Patients about Cardiovascular
Adverse Events and Psychiatric Adverse Events February 21, 2007 The
U.S. Food and Drug Administration (FDA) today directed the manufacturers of all
drug products approved for the treatment of Attention Deficit Hyperactivity
Disorder (ADHD) to develop Patient Medication Guides to alert patients to
possible cardiovascular risks and risks of adverse psychiatric symptoms
associated with the medicines, and to advise them of precautions that can be
taken.
On December 17, 2004,
the FDA required a warning be added to atomoxetine because of reports that two
patients (an adult and child) developed severe liver disease (both patients
recovered). In the clinical trials of 6,000 patients, no evidence of
hepatotoxicity was found. Patients who develop jaundice, dark urine, or other
symptoms of hepatic disease should discontinue atomoxetine. Routine monitoring
of hepatic function is not required during atomoxetine treatment.
In September of 2005,
the FDA also issued an alert regarding suicidal thinking with atomoxetine in
children and adolescents (Food and Drug Administration, 2005). In twelve
controlled trials involving 1,357 patients on atomoxetine and 851 on placebo,
the average risk of suicidal thinking was 4 per 1,000 in the atomoxetine-treated
group vs. none in those on placebo. There was one suicide attempt in the
atomoxetine group but no completed suicides. A boxed warning was added to the
atomoxetine labeling. This risk is quite small, but it should be discussed with
patients and family, and children should be monitored for the onset of suicidal
thinking, particularly in the first few months of treatment.
Recent
research on the utilization of
Straterra® (atomoxetine)
as compared to stimulants found that
children who start on Stratterra were 4.2 times more likely to change their
therapy than children who started on stimulants.
A review of all
long-term studies on stimulant medication and substance abuse, conducted by
researchers at Massachusetts General Hospital and Harvard Medical School, found
that teenagers with ADHD who remained on their medication during the teen years
had a lower likelihood of substance use or abuse than did ADHD adolescents who
were not taking medications.Ref
The information presented above is for
informational purposes only and does not take the place of advice from your
child’s physician.
Primary Sources:
American Academy of Pediatrics:
Clinical Practice Guideline: Treatment of the School-Aged Child With
Attention-Deficit/Hyperactivity Disorder PEDIATRICS Vol. 108 No. 4
October 2001, pp. 1033-1044
National Institute of Mental Health,
Attention Deficit
Hyperactivity Disorder 2006 (rev) NIH
Publication No. 3572 (This is a revision of Attention Deficit Hyperactivity
Disorder, a brochure first printed in 1994 and reprinted in 1996
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