Counseling Points - January 2009 - (Page 4)

Caring for Individuals with ADHD Throughout the Lifespan Pharmacologic Treatment Strategies for Children, Adolescents, and Adults with ADHD Introduction No treatment has been found to cure attention deficit hyperactivity disorder (ADHD), but there are a number of pharmacologic interventions that have been demonstrated to manage symptoms effectively.1-4 immediate-release formulations is about 4-6 hours, requiring dosing 2-3 times a day, whereas the long-acting agents can last for 10-12 hours. Most of the methylphenidate formulations are packaged as capsules (e.g., Focalin® XR, Ritalin LA®) that can be opened up and sprinkled on applesauce, but the modified formulation (Concerta®) cannot be cut, crushed, or chewed.8 The transdermal patch (DaytranaTM) should be applied to the hip 2 hours prior to activities, and it should be removed 9 hours after application.8 The effects of the methylphenidate patch are reported to continue for approximately 3 hours after removal. The duration of action of the short-acting (e.g., Dexedrine®) and intermediate-acting (e.g., Adderall®) dextroamphetamine formulations is approximately 4-8 hours, while that of the extended-release formulation (Adderall XR®) is approximately 8-12 hours.4,8 A dextroamphetamine-containing agent known as lisdexamfetamine (VyvanseTM) was released to the market recently. It is a pro-drug with dextroamphetamine and is covalently bound to L-lysine, and it is designed to decrease the abuse potential of this medication.8 Lisdexamfetamine is considered inactive until the L-lysine bond is cleaved within the gastrointestinal (GI) tract. Both methylphenidate and dextroamphetamine cause appetite suppression, but negative emotional symptoms are more often seen with dextroamphetamine than methylphenidate. 10 Other side effects include anorexia, weight loss, abdominal discomfort, and headache. Long-term use of stimulants may be associated with hypertension.11 In the past, stimulants were thought to cause growth suppression. Recent data have largely disproved this notion; effects have been noted on growth with longterm use, but these differences are not considered clinically significant.12,13 Controversy also exists as to whether or not stimulants cause tic disorder. Studies comparing stimulants with placebo have not shown an increase in tic disorder in subjects who are on therapy.14 Thus, tic disorders are not considered contraindications to using stimulants. Recently, rare cases of sudden cardiac death have been reported in pediatric subjects taking dextroamphetamine, which led to a labeling change for the medication.15,16 4 Medications for Children /Adolescents The primary goal of pharmacologic treatment for children and adolescents with ADHD is to improve their functioning in society (e.g., reduce disruptive behaviors, inattentiveness, and impulsivity, improve academic performance, and enhance relationships with others).1 Stimulants such as methylphenidate (Concerta®, DaytranaTM, Focalin ® , and Ritalin ® ) and dextroamphetamine (Adderall®, Dexedrine®, and VyvanseTM) are the drugs of choice for the initial treatment of ADHD in children and adolescents.4 At least 80% of children on stimulants will respond to these agents, which can help reduce the core symptoms of ADHD, such as inattention, hyperactivity and impulsivity.4-6 Stimulants Methylphenidate (available as dextromethylphenidate and methylphenidate) and dextroamphetamine (available as dextroamphetamine or mixed amphetamine salts) are the major stimulants used for ADHD management (Table 1). Pemoline was once used as a stimulant, but it was taken off the market in 2005 due to a risk of hepatotoxicity.7 Both types of stimulants produce similar response rates and side-effect profiles, and block the reuptake of norepinephrine and dopamine into the presynaptic neurons; these neurotransmitters are believed to play a significant role in ADHD.8 The clinical effects of stimulants include improvement in the core symptoms of inattention, hyperactivity, and impulsivity, and enhancement in quality of life and cognitive function.9 Methylphenidate is available in many different delivery systems and can be separated into short-acting and longacting formulations. Short-acting formulations are usually used during school activities, while long-acting formulations are used when extended (>10 hours) symptom relief is desired.4 Immediate-release, sustained-release, extended-release, modified-release, and transdermal formulations are available. The duration of effect of the COUNSELING POINTS™

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Counseling Points - January 2009

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