ADHD medication

The choice of ADHD medication should be made based on the patient s condition, the prescriber s familiarity with the medications, the ease of administration, and cost. Stimulants should be used first line in most ADHD patients, although there is no dear advantage of using one stimulant over another in managing symptoms of ADHD.16... 

Atomoxetine is similar to extended-acting stimulants in that it can be given once daily in many patients. Atomoxetine appears to lack any abuse potential and is not a controlled substance.22 One big disadvantage of atomoxetine is cost compared with other ADHD medications (Table 39-4). 

TABLE 39-3. ADHD Medication Side-Effect Profiles, Management, and Monitoring... 

TABLE 39-4. 30-Day Cost3 of Selected ADHD Medication Regimens... 

Norepinephrine-Blocking Medications. Medications that enhance dopamine activity and to a lesser extent those that enhance norepinephrine activity are believed to be the most successful treatments for ADHD. It may seem counterintuitive to try a medication that reduces norepinephrine turnover. The other ADHD medications... 

Children with Tourette s syndrome and ADHD refractory to other ADHD medication (n = 29) were treated openly with an average deprenyl dose of 8 mg/ day (Jankovic, 1993). The vast majority of patients (26/29) reported clinical improvement with no serious adverse outcomes. Mild side effects that did not require discontinuation of the drug were noted in six patients. Two patients had exacerbations of their tics. A later controlled trial of low-dose selegiline (10 mg/day) did not demonstrate statistically significant improvement of ADHD symptoms in children with Tourette s syndrome (Feigin et ah, 1996). 

Thus, at the national level, the most is known about the stimulants, particularly methylphenidate, rather than other classes of medications. The various data sets, whether based on NAMCS, pharmacteutical industry sources (NDTl), or the several state-level Medicaid databases, indicate that most of the stimulant medications are currently prescribed by primary care providers. Zarin et al. (1998b), drawing on the NAMCS 1995 data, noted that among primary care, psychiatry, and other specialties (such as neurology), 12.4% of all ADHD medication-related visits in the sample were to a psychiatrist, 75.4% to primary care physicians, and 12.2% to other specialties. 

According to the U.S. Centers for Disease Control (CDC) the number of prescriptions written for ADHD medications quadrupled between 1989 and 1998. And in 1999, both Adderall and Dexedrine were ranked among the top 200 for number of new drug prescriptions, rank-... 

One of the unfortunate realities of Ritalin use has been its propensity for abuse. A number of studies have revealed that grade-schoolers have obtained the drug from their peers who are undergoing therapy for ADHD. In one study published in 2001, 651 students aged 11-18 from Wisconsin and Minnesota were focused on. The researchers found that more than a third of the students who took ADHD medication said they had been asked to sell or trade their drugs. Users have crushed the pills and snorted the powder in order to get a cocaine-like rush. It is hoped that newer-generation products, e.g., time-release medications, will be less prone to this abuse since their formulation makes them more difficult to crush. 

Goodman, B. (2006, February 15). FDA warning on ADHD medications premature National ADHD advocacy group urges further research. Retrieved from http //www. newswire.ascribe.org... 

Rosack, J. (2006, March 3). FDA panel wants warnings on ADHD medications. Psychiatric News, p. 1. 

A 22-year-old man who had had ADHD since the age of 8 years took methylphenidate, and had an adequate response for 14 years (52). However, his symptoms worsened and he switched from methylphenidate to mixed amfetamine salts 20 mg bd. A month later he continued to have difficulty in focusing on tasks, and the dosage was eventually increased to 45 mg tds over several weeks, with symptomatic improvement. However, 5 days later, he awoke feeling nauseated and agitated and had choreiform movements of his face, trunk, and limbs. He had also taken escitalopram 10 mg/day for anxiety and depression for 2 months before any changes in his ADHD medications. He was treated with intravenous diphenhydramine, lora-zepam, and diazepam without improvement in the chorea. Amfetamine was withdrawn and 3 days later his chorea abated. He restarted methylphenidate and the movement disorders did not recur. 

The nonmedical use of prescription drugs has evolved toward a severe health issue worldwide. To date, prescription drugs are the second of abused substances after marijuana in teens in the United States (White House ONDCP, 2014) and include pain killers (opioids), stimulants (ADHD medication), and antidepressants. 

Cortese S, Holtmann M, Banaschewski T, Buitelaar J, CoghiU D, Danckaerts M, et al. Practitioner review current best practice in the management of adverse events during treatment with ADHD medications in children and adolescents. J Child Psychol Psychiatry and Allied DiscipHnes 2013 54(3) 227-A6. 

The main indication for certain psychostimulants is ADHD in children and adults [4]. Recent research shows that the clinical effect and benefit are dramatic even in adults. About 60% of adult patients receiving stimulant medication showed moderate-to-marked improvement, as compared with 10% of those receiving placebo. The core symptoms of hyperactivity,... 

Patient Encounter, Part 2 Medical History, Physical Examination, and ADHD Evaluation... 

Behavioral therapy can be used to treat patients with ADHD however, it is generally not recommended as first-line monotherapy.8 Several studies have demonstrated that treatment with medication alone is superior to behavioral intervention alone in improving attention.12 However, behavioral therapy in combination with stimulant therapy was better at improving oppositional and aggressive behaviors.12 Behavioral modification involves training parents, teachers, and caregivers to change the physical and social environment and establishment... 

The proposed mechanism of ADHD pharmacotherapy is to modulate neurotransmitters in order to improve academic and social functioning. Pharmacologic therapy can be divided into two categories stimulants and non-stimulants. Stimulant medications include methylphenidate, dexmethylphenidate, amphetamine salts, and dextroamphetamine, whereas non-stimulant medications include atomoxetine, tricyclic antidepressants (e.g., imipramine), clonidine, guanfacine, and bupropion. 

Psychostimulants (e.g., methylphenidate and dextroamphetamine with or without amphetamine) are the most effective agents in treating ADHD. Once the diagnosis of ADHD has been made, a stimulant medication should be used first line in treating ADHD (Fig. 39-1). Stimulants are safe and effective, with a response rate of 70% to 90% in patients with ADHD.3,13,14 Generally, a trial of at least 3 months on a stimulant is appropriate, and this includes dose titration to response... 

Atomoxetine is the most recent addition to the ADHD armamentarium in both children and adults. In clinical studies, atomoxetine has demonstrated superior efficacy over placebo and equivalent efficacy when compared with a suboptimal immediate-release methylphenidate dose.17 20 However, it is not clear whether atomoxetine is superior to typical methylphenidate doses or other stimulant formulations. Atomoxetine may be used as a second- or third-line medication for ADHD. 

In 1970, the U.S. government passed the original Controlled Substances Act, and under this law methamphetamine was classified as a Schedule II drug in its injectable form and a Schedule III in its noninjectable (pill) form. However, a year later, both forms of methamphetamine were reclassified as Schedule II drugs. Today, it is still sold under the name Des-oxyn for a few medical uses, such as for the treatment of atten-tion-deficit/hyperactivity disorder (ADHD) and narcolepsy. 

Some psychiatric medications also produce a response within minutes of taking a single dose. Their therapeutic benefit can come very quickly. For example, taking a benzodiazepine such as diazepam (Valium) can quickly relieve panic and anxiety. Taking a stimulant can often rapidly relieve the symptoms of attention deficit-hyperactivity disorder (ADHD). When psychiatric medications work this quickly, we assume that the therapeutic benefit is a direct consequence of their initiating action in the synapse. 

Of greater concern is the safety of the TCAs. Toxic levels of these medications can produce lethal cardiac arrhythmias, seizures, and suppression of breathing. An overdose of a 1-2 week supply of most TCAs is often fatal, a serious consideration when prescribing medication to depressed patients with suicidal thoughts. Children taking imipramine for treatment of ADHD have died from sudden cardiac death consequently, child psychiatrists seldom use TCAs. Likewise, patients with heart disease or seizure disorders are more likely to have dangerous complications from TCAs and should avoid them. 

Substance-Induced Anxiety Disorder. Numerous medicines and drugs of abuse can produce panic attacks. Panic attacks can be triggered by central nervous system stimulants such as cocaine, methamphetamine, caffeine, over-the-counter herbal stimulants such as ephedra, or any of the medications commonly used to treat narcolepsy and ADHD, including psychostimulants and modafinil. Thyroid supplementation with thyroxine (Synthroid) or triiodothyronine (Cytomel) can rarely produce panic attacks. Abrupt withdrawal from central nervous system depressants such as alcohol, barbiturates, and benzodiazepines can cause panic attacks as well. This can be especially problematic with short-acting benzodiazepines such as alprazolam (Xanax), which is an effective treatment for panic disorder but which has been associated with between dose withdrawal symptoms. 

In the past several years, attention deficit-hyperactivity disorder (ADHD) has received considerable attention from both the lay public and the medical and psychological communities. It has become one of the more controversial of the psychiatric disorders. There are several factors that contribute to this phenomenon. 

Althongh some gronps have used the controversy snrronnding ADHD as a platform to attack the nse of psychiatric medications as a whole, we should not in onr haste to dismiss snch perspectives overlook the fact that these are fair and reasonable qnestions. For that reason, we will try in this chapter to address these questions as we discnss the diagnosis, the long-term conrse, and the treatment of ADHD. The treatment options have recently expanded with the FDA approval of atomoxetine (Strattera), a selective norepinephrine renptake inhibitor that is not a psychostimn-lant, for the treatment of ADHD. 

ADHD may continue into adulthood. This issue has been debated not only in medical journals but on TV talk shows and in news magazines as well. However, adult ADHD is no trivial matter. Certainly, the physical hyperactivity of the 6 year old with ADHD is not so readily evident in the 26 or 36 year old. Nevertheless, some individuals with ADHD continue to be plagued by impulsive outbursts of anger and poor concentration even after they reach adulthood. This continues to take a toll as it often leads to marital strife and problems holding a job. Like the child and adolescent with ADHD, adults with the disorder are often considered underachievers and may even be dismissed as lazy. 

Impulsivity is manifested by a hot temper or quick decision making that is later regretted. Finally, adults with ADHD often have significant problems with alcohol or illicit substance abuse. They may also heavily use caffeine or cigarettes. This pattern of substance use is likely, in part, an attempt to medicate the illness. 

The most successful treatments for ADHD have been those that increase the activity of the neurotransmitters dopamine and norepinephrine. It has been known for some time that our brains nse these two substances to focns attention during response to challenging or stressfnl situations. The theory that medications that increase the activity of either dopamine and/or norepinephrine would be good treatments for ADHD has largely proved true, and we now have medications that can help children and adults with ADHD tremendously. 

But there are patients with ADHD who continue to have problems with impulsiv-ity despite these treatments. This has led to several innovative approaches to help address these residual symptoms with medications ranging from antidepressants to mood stabilizers, antipsychotics, and even medicines that are more commonly used to treat high blood pressure. The problem here is finding a medication that will alleviate the remaining impulsivity without worsening the problems with attention. There has been modest success with these more difficult cases, but there remains room for improvement. 

Methylphenidate (Ritalin). Methylphenidate was developed in the late 1950s and its first use was the treatment of what we now call ADHD. Since that time, it has also been approved for the treatment of narcolepsy. Its only other use is the treatment of severe refractory depression either in medically ill patients who need rapid clinical improvement or as an augmentation agent when added to other antidepressants. In the treatment of ADHD, methylphenidate not only improves attention but also reduces hyperactivity and impulsivity. Verbal and physical aggression typically decreases as well. 

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