Counseling Points - January 2009 - (Page 9)

and titrate slowly, addressing any side effects as they present. Side effects tend to emerge early in treatment and generally go away within the first couple weeks of treatment. Third, it is important to individualize the treatment for each person depending on the identified ADHD subtype (inattentive, hyperactive-impulsive, or a combination of the two). 1 In general, co-morbidities should be addressed first. Any prior ADHD treatment should be documented. If a family member has been treated with stimulants, discuss their response. Consider the person’s age, level of need for treatment, and the times during the day when medication would be most effective. Use this information to choose a stimulant with the onset and duration to meet this need. Elicit and discuss the individual’s views on taking medication, type of insurance coverage, and the affordability of medications. It is important to educate adults who do not have prescription coverage that they can access medications through patient assistance programs offered by most drug companies. The website www.needymeds.com is an excellent resource in this regard. It is also important to be aware of any coexisting medical conditions or concomitant treatments when considering the use of stimulants. Impairments and treatment goals should be identified and documented so that the individual’s response can be measured against them, and baseline information on height, weight, blood pressure (BP), and heart rate should be obtained and updated periodically during treatment. Discuss with the individual how to handle any questions or concerns that may arise before the next scheduled visit. Set up an agreed-upon schedule for monitoring efficacy and side effects, and titrating the dose. Stimulant Treatments for ADHD in Adults Arnold et al. reviewed studies in which subjects underwent a trial of both amphetamine and methylphenidate.53 This review suggested that approximately 41% of subjects with ADHD responded equally to both methylphenidate and amphetamine, whereas 44% responded preferentially to one of the classes of stimulants. This translated into a predicted response rate of 80% to 85% to one or the other class of stimulants. Adult overall response (a 30%50% improvement in symptoms) to stimulants has been estimated at 60%-70%, with 30% experiencing significant improvement, 40% showing some improvement, and 10%-30% not responding.54 Maximum doses for stimulants have been identified based on children and adolescents. Research with adults to date has indicated a need for higher doses in adults to achieve a significant response. At this time, the FDA has approved Adderall XR®, Focalin® XR, and VyvanseTM as stimulant treatments for adults.52 Impacts to the Effectiveness of Stimulants Certain substances may alter the serum levels of stimulants. Urinary alkalinizers, potassium, sodium citrate, and thiazides may increase renal tubular re-absorption, which decreases elimination of stimulants and increases their effects. Urinary acidifiers, ammonium chloride, sodium acid phosphate, and vitamin C may increase renal elimination of stimulants and decrease their effects.22 Adults should be cautioned against taking their medication with acidic fruit juices, sports drinks, vitamin C, or glutamic acid, as these decrease the absorption of amphetamines, or akalinizing agents such as sodium bicarbonate, which increase the absorption of amphetamines.55 Taking stimulants after a high-fat meal may delay absorption. CYP2D6 inhibitors may increase serum levels of stimulants, and caution should be used with stimulants and serotonins as the combination may result in serotonin syndrome.22 Assessing for Adverse Events During follow-up appointments, measure the response to treatment in reference to the identified impairments and treatment goals and document any changes. As with any medication, ADHD drugs can produce side effects and addressing these as they arise will improve adherence. Often, the side effects from stimulants are transient and will subside within a week.The most common side effects are decreased appetite, anxiety, weight loss, insomnia, and/or headache; less commonly seen but more significant side effects of stimulants include movement disorders, increased anxiety, and emotional lability/irritability.10,22,51 The clinician should also be familiar with the precautions and reported adverse events contained in product labeling. Most of the time these side effects can be managed by delaying an increase in the dose, decreasing the dose, or switching to another stimulant.52 In some cases where the benefits are robust, it may be feasible to treat the side effect with adjunctive pharmacology.52 9 Contraindications to Stimulants Contraindications for the use of stimulants in adults include any prior history of sensitivity to stimulants, glaucoma, symptomatic cardiovascular disease, hyperthyroidism, and current substance abuse. Other contraindications include unstable mood, psychosis, marked anxiety, motor tics, uncontrolled seizure disorders, and concomitant use of monoamine oxidase inhibitors (MAOIs).54 Recent reports of cardiac problems and the resulting Black Box Warning on the package labeling for stimulants (as detailed in the section on children and adolescents) has been a source of concern for clinicians. In the American Academy of Child and Adolescent Psychiatry’s publication on practice parameters for ADHD in children, the JANUARY 2009 http://www.needymeds.com

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Counseling Points - January 2009

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