ATX ADDED TO STIMULANTS

Some patients with ADHD obtain a robust response from stimulants for most of their ADHD symptoms or for most of the day, but not for the full range of impairing symptoms or the full span of time needed.

Case I

Jimmy, an 8-year-old boy in second grade, had been diagnosed with ADHD-combined type while in kindergarten. He was doing well throughout the school day on OROS® MPH 27 mg q 7 a.m., but this dose wore off by 4p.m., leaving the boy restless, irritable, and severely oppositional for the ensuing 5 hours until his bedtime. During this time Jimmy was unable to focus on homework and often engaged in hostile interactions with playmates and family. He also was very irritable and oppositional every morning for about an hour until his OROS MPH had taken effect. In addition, Jimmy had chronic difficulty falling asleep, a longstanding problem that antedated his being on stimulant medication. Doses of 2.5, 5, and 7.5 mg immediate release MPH (MPH-IR) were tried at 3:30 p.m. to supplement the morning dose of OROS MPH. The 2.5- and 5-mg doses were ineffective; the 7.5-mg dose after school was helpful in alleviating Jimmy's irritability and oppositional behaviour after school and in the evening. This regimen had to be discontinued, however, because it left Jimmy with severely diminished appetite for afternoon and evening, a serious problem for this boy who was underweight. The 3:30 p.m. dose also exacerbated his chronic difficulty in falling asleep. Clonidine 0.1mg 1/2 tab q 3:30 p.m. and 1 tab hs was helpful in alleviating afternoon irritability and the difficulty failing asleep but did not help his impaired focus for homework or the serious problems with morning routine that were very stressful for the entire household.

Clonidine was discontinued, and a trial of ATX 18 mg qam was begun while continuing the OROS MPH. Jimmy's sleep problems improved markedly within a few days. His irritability and oppositionality improved slightly within a few days and significantly over the next 3 weeks after the dose of ATX had been increased to 36 mg at the end of the first week. In addition, after 3 weeks, parents reported that Jimmy was generally much less irritable upon awakening and much more cooperative with morning routines, even during the hour before his OROS MPH took effect. Patient has continued in this OROS MPH and ATX regimen for 4 months with continuing benefit and no adverse effects. Appetite is still somewhat problematic in the evening but much less so than during the treatment with an afternoon dose of MPH-IR.

This case highlights the usefulness of ATX for alleviating difficulties in falling asleep and for improving oppositional behaviour in late afternoon, early evening, and morning, times when the OROS MPH had either worn off or not yet taken effect. It was not clear whether ATX had enhanced positive effects of the MPH during daytime hours, but no negative effects were reported. The benefits of ATX were obtained without the adverse effects that accompanied the trials of MPH-IR administered after school.

Case 2

Jennifer, a 17-year-old high school junior had been diagnosed with ADFID, predominantly inattentive type, in ninth grade. She was treated initially with Adderall-XR® 20 mg administered q 6:30 a.m. as she left for school. Adderall-XR provided coverage only until about 4:30 p.m., which was sufficient for days when homework assignments were relatively light and could be done immediately after school.

At the outset of her junior year, Jennifer and her parents requested medication adjustments that would extend coverage into the evening. Because of part-time employment after school, Jennifer now had to do her homework in the evening. Also she was now driving herself to and from school, to and from her job, and to other activities. After she had a minor motor vehicle accident caused by her being inattentive, Jennifer and her parents decided it would be important for her to have medication coverage in the evening to help her with homework and to improve her attention when driving.

Jennifer's morning dose was maintained at 20 mg of Adderall-XR, and Adderall-IR 10 mg was added at 3:30 p.m. This provided coverage until about 10 p.m, but it caused Jennifer to feel extremely restless and anxious in late afternoon. These adverse effects were not alleviated by reducing the dose of Adderall-IR to 5 mg. Moreover, the lower dose of JR did not provide enough symptom control for Jennifer in the evening for homework, so she had to quit her after school job.

When ATX became available, Jennifer was started on ATX 18 mg qam for 1 week concurrent to the existing regimen of Adderall-XR 20 mg qam. After a couple of days of feeling somnolent on this combination, she reported no other adverse effects and some slight improvement in her ability to get homework done in the evening. ATX was increased to 40 mg qam. She experienced 2 days of somnolence on this increased dose, but this dissipated on the third day.

Over the next 3 weeks, Jennifer reported feeling calmer, more focused, and more alert throughout the day and into the evening until bedtime. For 5 months Jennifer and her parents have continued to report good control of her ADHD symptoms throughout the day and evening, with no adverse effects reported.

Jennifer was able to tolerate and benefit from the Adderall-XR given in the morning, but she did not respond well when a second dose of Adderall was given in the afternoon. The combination of Adderall-XR with Adderall-IR seemed to produce an accumulated level by late afternoon that caused her marked restlessness and anxiety The combination of Adderall-XR with ATX allowed better alleviation of ADHD symptoms throughout the day and into afternoon and evening. On this regimen, Jennifer did not feel anxious or restless and was able to do well during school, complete her homework in the evening, and resume her after school job. She also reported that she felt more focused when driving in the evening, at times when the stimulant would be expected to have lost effectiveness. Expanded duration of medication coverage, especially for evenings and weekends, for drivers with ADHD may provide important protection from elevated safety risks reported for drivers with this disorder (Barkley et al. 2002).