Let's Focus on ADHD
Dr. Hieber is a clinical pharmacist at Western Missouri Mental Health Center in Kansas City, Missouri. Dr. Purvis is a psychiatry pharmacy resident at Western Missouri Mental Health Center.
Though previously thought to be a childhood disorder, attention-deficit/hyperactivity disorder (ADHD) is now known to persist into adulthood.1 "Growing out" of ADHD is unlikely; rather, one may learn to compensate for the impairment. Hyperactive symptoms may subside in adulthood, with inattentive symptoms becoming more prevalent. In both children and adults, ADHD can negatively affect socialization, school or occupational work, and relationships.
Affecting 8.7% of children and 4.4% of adults, ADHD is hereditary.2,3 Several genes related to transmission of the neurotransmitter dopamine, and to a lesser extent, norepinephrine and serotonin, are implicated in ADHD.4 These neurotransmitters are associated with the brain's arousal network, which can be stimulated inappropriately in one who has ADHD. Other risk factors found in ADHD include prenatal exposure to tobacco or alcohol, low birth weight, and perinatal complications.5
According to the Diagnostic and Statistical Manual of Mental Disorders, an individual with ADHD displays developmentally inappropriate levels of inattention, hyperactivity, and impulsivity persisting for at least 6 months.6 Presentation ranges from difficulty organizing tasks and forgetfulness in daily activities to excessive talking and interrupting others. Symptoms must begin in childhood, be present in 2 or more settings, and cause marked impairment in functioning. Despite this impairment, a number of effective treatment options exist for people with ADHD.
Up to 80% of individuals with ADHD respond to stimulants; therefore, these agents are first-line options for both children and adults.6,7 By enhancing the neurotransmission of dopamine and norepinephrine, stimulants have the greatest effect on social and classroom behaviors.8 The benefit of stimulants will often appear within days of achieving an adequate dose.
Evidence-based reviews conclude that all stimulant medications are equally effective, though an individual may respond to one stimulant over another.7,9 Stimulants are available in short-acting, intermediate-acting, and long-acting formulations.10 Short-acting and intermediate-acting medications' peak effect occurs 1 to 3 hours after administration, necessitating the need for multiple daily dosing. School-age children may benefit from long-acting agents that eliminate the need for midday dosing. Depending on the formulation of the medication, ease of administration may be increased by crushing short-acting or intermediate-acting agents, or sprinkling the contents of a long-acting capsule over food.
Over the past decade, the advancement of new formulations has led to an increase in the use of long-acting agents. Examples include an osmotically controlled-release drug delivery system (methylphenidate HCl, Concerta), transdermal methylphenidate patch (methylphenidate transdermal system, Daytrana), and a conjugated d-amphetamine molecule (lisdexamfetamine dimesylate capsules, Vyvanse). Along with simplifying dosage regimens, these options were developed to decrease diversion and abuse of the medications.10
Guidelines suggest initiation with a low dose to minimize side effects and achieve the lowest effective dose.6,11 Decreased appetite, sleep and gastrointestinal disturbances, irritability, headache, tachycardia, and jitteriness8,12 are common, but often transient side effects. Although reported clinically, growth suppression was not reported consistently in clinical trials.13 Stimulants may cause a minimal increase in heart rate and blood pressure (dose-related); experts recommend that those treated with stimulants are monitored at baseline and periodically throughout treatment, especially children with underlying cardiac abnormalities or arrhythmias.14,15 Whereas studies have not shown an association between stimulants and changes in electrocardiograms, monitoring is recommended in high-risk patients. Medications used to treat ADHD contain an FDA warning about the possible cardiovascular risks and psychiatric adverse events,16 along with a manufacturer's warning indicating the potential for abuse.
Atomoxetine (Strattera) is the only FDA-approved nonstimulant medication used as a major second-line, and in some cases first-line treatment for ADHD (those with a history or concern of substance abuse).6,11,17,18 The drug is a selective norepinephrine reuptake inhibitor and has a slower onset of action than stimulants. It may take 2 to 4 weeks to determine clinical effectiveness. Side effects are similar to stimulants; however, an increase in sedation and sexual disturbances have been reported. Suicidal ideation and hepatotoxicity have been reported in the literature, and this risk is included in the manufacturer's warning label.19
Second-line treatment options should be considered for patients who have failed 2 to 3 stimulant medications. Along with atomoxetine, antidepressants (eg, venlafaxine, bupropion, tricyclic antidepressants) are second- or third-line agents.17,20-22 These have shown only modest efficacy for the treatment of ADHD, but may be beneficial for patients with comorbid depression or substance abuse.
Several studies have indicated that modafinil, approved for treating narcolepsy, has shown improvement in ADHD.23 Concerns of Stevens-Johnson syndrome led an FDA advisory committee to recommend against approval of modafinil for the treatment of ADHD in children. Clonidine and guanfacine, a2-adrenergic agonists, may be adjunctive treatment options in children with ADHD, especially those experiencing sleep disturbances.24-26
Behavioral interventions were not more effective than medication, according to recent evidence.27 Pharmacists can play a major role in educating patients and caregivers.
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19. Abboud L. Lilly warns doctors about Strattera. Wall Street Journal. December 20, 2004:B4.
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24. Conner DF, Fletcher KE, Swanson JM. A meta-analysis of clonidine for symptoms of attention deficit hyperactivity disorder. J Am Acad Child Adolesc Psychiatry. 1999:38(12);1551-1559.
25. Scahill L, Chappell PB, Kim YS, et al. A placebo-controlled study of guanfacine in the treatment of children with tic disorders and attention deficit hyperactivity disorder. Am J Psychiatry. 2001;158(7):1067-1074.
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29. Adderall [package insert]. Princeton, NJ: Sandoz Inc;2007. Accessed April 30, 2009.
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31. Vyvanse [package insert]. Wayne, PA: Shire Pharmaceuticals; 2007. Accessed April 30, 2009.
32. Concerta [package insert]. Mountain View, CA: ALZA Corp;2007. Accessed April 30, 2009.
33. Focalin [package insert]. East Hanover, NJ: Novartis Pharmaceuticals Corp; 2007. Accessed April 30, 2009.
34. Methylphenidate extended-release [package insert]. Corona, CA: Watson Laboratories;2007. Accessed April 30, 2009.