Magazine article Drug Topics

No Child's Play

Magazine article Drug Topics

No Child's Play

Article excerpt

More drug options now available for ADHD patients

Editor's note: The following article was written by Gary M. Levin, Pharm.D., BCPP, associate professor of pharmacy, Albany College of Pharmacy, and medical staff associate, Capital District Psychiatric Center, Albany, N.Y. When school starts next month, teachers will again be confronted with the opportunity of recognizing children with attention deficit hyperactivity disorder (ADHD). Fortunately, there are more pharmacotherapeutic options available today for ADHD.

ADHD occurs in 2%-9% of schoolage children and 1%-3% of adultsand more commonly in males than females. Although the formal diagnosis requires that symptoms must have been present before the age of seven, the most common age of actual diagnosis is nine. While there are various treatment options for patients with ADHD, this article will focus only on pharmacotherapy. Drug treatments are similar for both children and adults, with higher dosages used in adults.

Several important factors must be considered before a pharmacologic agent is recommended. First is severity of illness. Many patients with mild symptoms can be treated without medication. However, moderate to severely ill patients will almost always require medication. The next step is to determine if the patient has any other medical or psychiatric illnesses and if he or she is receiving medications for those illnesses. Prescreening should be conducted to select an agent that will not interact with other medications.

Many adult patients and parents of pediatric patients will struggle with the concept of taking psychostimulants or antidepressants (or having their children take them) because of the negative connotations society has placed on both mental illness and medication use.

Psychostimulants are recognized as the pharmacologic agents of choice for treating ADHD (Table 1). The efficacy rate of the stimulants is between 80% and 90%. In a patient that fails treatment with the first stimulant tried, the efficacy rate can be increased to 95% by switching to a second one. There should be a satisfactory stimulant for most patients; however, some patients may not tolerate the drugs or may have a disease state with a contraindication to them.

These agents exert their pharmacologic effect by increasing the release of dopamine and norepinephrine. It is not clearly understood why this helps in treating ADHD; however, these agents cause a stimulation of the central nervous system that seems to help patients remain focused on their particular tasks. The stimulants have a rapid onset of effect and a relatively short duration of action, unless sustained-release products or pemoline (Cylert, Abbott Laboratories) is used.

Almost all of the stimulants are available in generic form. Monitoring parameters should include complete hematology, electroencephalogram (EEG), electrocardiograph (EKG), and liverfunction tests.

Some stimulants are available in a sustained-release (SR) formulation. These agents can often be taken once daily and are designed to deliver a similar amount of drug as several daily doses of a lesserstrength immediate-release formulation (IR). One problem often encountered with the use of SR products is that patients do not receive the rapid peak plasma concentration, and onset of effect is therefore delayed. This can be countered by taking a low dose of IR at the same time as the mornin SR dose.

Common side effects of the stimulants include insomnia, appetite suppression, stomachache, headache, and potentially increased heart rate and blood pressure. Although insomnia is always included in product information for all of the stimulants, it has been demonstrated under rigorous study design that methylphenidate, when given as a 4 P.M. dose (in addition to two earlier dosages), had no effect on sleep latency. If any type of tics develop, the stimulants should be discontinued. Some children have developed tics and have later developed Tourette syndrome. …

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