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Attention Deficit Hyperactivity Disorder Medication Prescribing Practice:
Unlike most other medications, stimulant dosages usually are not weight dependent. Clinicians should begin with a low dose of medication and titrate upward because of the marked individual variability in the dose-response relationship. The first dose that a child's symptoms respond to may not be the best dose to improve function. Clinicians should continue to use higher doses to achieve better responses. This strategy may require reducing the dose when a higher dose produces side effects or no further improvement. The best dose of medication for a given child is the one that leads to optimal effects with minimal side effects. The dosing schedules vary depending on target outcomes, although no consistent controlled studies compare different dosing schedules. For example, if there is a need for relief of symptoms only during school, a 5-day schedule may be sufficient. By contrast, a need for relief of symptoms at home and school suggests a 7-day schedule.
According to the AAP Treatment Guidelines, at least 80% of children will respond to one of the stimulants if they are tried in a systematic way. Children who fail to show positive effects or who experience intolerable side effects on one stimulant medication should be tried on another of the recommended stimulant medications. Children who fail 2 stimulant medications can be tried on a third type or formulation of stimulant medication for the same reason. The next step would be to review the history and symptoms to confirm the diagnosis. Primary care physicians most likely will consider referral to a child and adolescent psychiatrist at this point. Bupropion, tricyclic antidepressants (TCAs), and alpha-agonists are often used in the treatment of ADHD even though they are not approved by the FDA for this purpose. Although there is at least one double blind, randomized controlled trial for bupropion, TCAs and Clonidine, the evidence base for these medications is far weaker than for the FDA-approved agents. [An article from the University of Maryland addresses selection of medication for ADHD treatment]
ADHD Medication Side Effects:
Stimulants are generally considered safe medications, with few contraindications to their use. Side effects occur early in treatment and tend to be mild and short-lived. The most common side effects are decreased appetite, stomachache or headache, delayed sleep onset, jitteriness, or social withdrawal. Most of these symptoms can be successfully managed through adjustments in the dosage or schedule of medication. Approximately 15% to 30% of children experience motor tics, most of which are transient, while on stimulant medications. In addition, approximately half of children with Tourette syndrome have ADHD. The effects of medication on tics are unpredictable. The presence of tics before or during medical management of ADHD is not an absolute contraindication to the use of stimulant medications. A review of 7 studies comparing stimulants with placebo or with other medications indicated no increase in tics in children treated with stimulants.
Safety Issues Related to ADHD Medicines:
Patients treated with medication for ADHD should have their height and weight monitored throughout treatment. If the patient has a change in height or weight that crosses 2 percentile lines, this suggests an aberrant growth trajectory. In these cases, a drug holiday should be considered, if return of symptoms during weekends or summers does not lead to marked impairment of functioning. The clinician should also consider switching the patient to another ADHD medication. It is important for the clinician to carefully balance the benefits of medication treatment with the risks of small reductions in height gain, which as of yet have not shown to be related to reductions in adult height.
FDA Directs ADHD Drug Manufacturers to Notify Patients about Cardiovascular Adverse Events and Psychiatric Adverse Events February 21, 2007 The U.S. Food and Drug Administration (FDA) today directed the manufacturers of all drug products approved for the treatment of Attention Deficit Hyperactivity Disorder (ADHD) to develop Patient Medication Guides to alert patients to possible cardiovascular risks and risks of adverse psychiatric symptoms associated with the medicines, and to advise them of precautions that can be taken.
On December 17, 2004, the FDA required a warning be added to atomoxetine because of reports that two patients (an adult and child) developed severe liver disease (both patients recovered). In the clinical trials of 6,000 patients, no evidence of hepatotoxicity was found. Patients who develop jaundice, dark urine, or other symptoms of hepatic disease should discontinue atomoxetine. Routine monitoring of hepatic function is not required during atomoxetine treatment.
In September of 2005, the FDA also issued an alert regarding suicidal thinking with atomoxetine in children and adolescents (Food and Drug Administration, 2005). In twelve controlled trials involving 1,357 patients on atomoxetine and 851 on placebo, the average risk of suicidal thinking was 4 per 1,000 in the atomoxetine-treated group vs. none in those on placebo. There was one suicide attempt in the atomoxetine group but no completed suicides. A boxed warning was added to the atomoxetine labeling. This risk is quite small, but it should be discussed with patients and family, and children should be monitored for the onset of suicidal thinking, particularly in the first few months of treatment.
Recent research on the utilization of Straterra® (atomoxetine) as compared to stimulants found that children who start on Stratterra were 4.2 times more likely to change their therapy than children who started on stimulants.
A review of all long-term studies on stimulant medication and substance abuse, conducted by researchers at Massachusetts General Hospital and Harvard Medical School, found that teenagers with ADHD who remained on their medication during the teen years had a lower likelihood of substance use or abuse than did ADHD adolescents who were not taking medications.
The information presented above is for informational purposes only and does not take the place of advice from your child’s physician.
Primary Sources:
American Academy of Pediatrics: Clinical Practice Guideline: Treatment of the School-Aged Child With Attention-Deficit/Hyperactivity Disorder PEDIATRICS Vol. 108 No. 4 October 2001, pp. 1033-1044
National Institute of Mental Health, Attention Deficit Hyperactivity Disorder 2006 (rev) NIH Publication No. 3572 (This is a revision of Attention Deficit Hyperactivity Disorder, a brochure first printed in 1994 and reprinted in 1996
next: Parenting Skills - For Parents of Children with ADHD
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