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Update On Medications To Treat ADD (ADHD)
By Patricia Quinn, M.D.
(adapted by Patricia Quinn from Gender Issues and AD/HD)
Research and clinical experience have shown that stimulant
medications are the most effective first-line treatment for
ADD (ADHD). Currently, there are many new medications to treat
ADD (ADHD). Although many parents and educators continue to
voice concerns over the prescription of medication for children
with ADD (ADHD), recent studies suggest that stimulant medication
is the most effective treatment option for children with ADD
(ADHD) and that, in some studies, medication alone has a positive
treatment effect equal to medication in combination with cognitive/behavioral
therapy.
Methylphenidate based products (Ritalin, Ritalin
LA, Concerta, Metadate)
For a number of years, methylphenidate was available only
as Ritalin with a duration of action (the length of time its
beneficial clinical effects can be observed) of approximately
3-4 hours. Because of this short half-life, methylphenidate
required multiple daily doses to obtain clinical benefits
throughout the day. Recently, a number of other methylphenidate
products have become available (e.g., Concerta, Metadate CD,
Ritalin LA) that require only once daily dosing to address
ADD (ADHD) symptoms throughout the day. These products use
different delivery systems that allow for a slow release of
medication throughout the day and have been shown to have
pharmacological and clinical profiles comparable to twice
a day (b.i.d) or three times a day (t.i.d.) dosing with typically
formulated methylphenidate. To date, there is little evidence
to support the superiority of any one of the once-daily products
over the others.
| Products |
Concerta® |
Metadate® CD |
Ritalin® LA |
| FormulationTechnology |
OROS® |
Diffucaps® |
SODAS™ |
| Dose Available |
18/27/36/54 mg |
20 mg |
20/30/40 mg |
| Immediate (%) |
22% |
30% |
50% |
| 1st release (dose amt) |
4/6/8/12 mg |
6 mg |
10/15/20 mg |
| Sustained (%) |
78% |
70% |
50% |
| 2nd release (dose amt) |
14/21/28/42 mg |
14 mg |
10/15/20 mg |
Amphetamine-Based Products (Dexedrine, Adderall,
Adderall XR)
Both Dexedrine and Adderall are trade names for products whose
active component is some form of amphetamine. Dexedrine, which
has been available for a number of years, is equally effective
as methylphenidate for a number of problems associated with
ADD (ADHD), but is not prescribed as frequently.
Adderall is the trade name for a generic compound of mixed
amphetamine salts (three forms of d-amphetamine and one of
l-amphetamine). It has become available for treatment of ADD
(ADHD) relatively recently compared with the other stimulants
and is now available as a once daily formulation (Adderall
XR). Adderall, which has been studied primarily in children,
has been shown to be equally as effective as methylphenidate
in reducing disruptive behaviors in a classroom setting, improving
parent and teacher behavior ratings, and improving academic
performance. It is recommended that the maximum daily dose
not exceed 40 mg (PDR). It has been reported that the duration
of behavioral effects or of Adderall is generally dose-dependent,
with higher doses resulting in longer duration of action (e.g.,
5 mg = 3.52 hours; 20 mg = 6.40 hours). This same study found
similar results for the time of peak effects for Adderall
with lower doses resulting in shorter times to peak effects
(e.g., 5 mg = 1.5 hours; 20 mg = 3.0 hours). In general, both
the duration of action and the time to peak effects is longer
for Adderall compared to methylphenidate The half-life of
Adderall has not been conclusively determined, but given its
chemical composition, it would be expected to be similar to
that for Dexedrine! (e.g., 6-7 hours). Adderall XR has a much
longer duration of action (e.g. 10-12 hours).
The following table lists medications to treat ADD
(ADHD) and duration of action
| Ritalin methylphenidate |
(3-4 hours) |
| Focalin™: a refined form of Ritalin®, isolating
only the effective isomer |
(3-4 hours) |
| Dexedrine dextroamphetamine |
(4-5 hours) |
| Adderall mixed amphetamine salts |
(4-6 hours) |
| Ritalin® LA (once-daily
formulation of Ritalin® that mimics BID dosing and
duration and is designed to last the school day) |
6-8 hours |
| Adderall XR™ (extended-release
formulation of mixed amphetamines that mimics BID dosing)
|
8-12 hours |
| Metadate® CD (methylphenidate formulation
designed to mimic BID) |
4-8 hours |
| Concerta® (methylphenidate formulated
to mimic TID duration) |
10-12 hours |
| Dexedrine Spansules (longer-acting
amphetamine) |
8-10 hours |
Side Effects
The main side effects of stimulants are appetite
suppression and insomnia. It appears, however, that these
side effects are not as severe with the long-acting stimulants.
In addition, long-acting stimulants are smoother and keep
symptoms at bay for many hours on end without the feelings
of medication effects starting and stopping throughout the
day. This long-duration may help the student address not only
symptoms causing academic difficulties but also those that
can affect social and daily-living activities.
Atomoxetine (Strattera)
Strattera is a selective norepinephrine re-uptake
inhibitor, which is indicated for the treatment of ADHD in
children, adolescents, and adults. To date, 1109 children
and adolescents and 536 adults have been included in double-blind,
controlled trials. Strattera is currently the only agent that
has an FDA-approved indication for treatment of adult ADD
(ADHD).
The mode of action of Strattera in the treatment of ADHD
is currently not known. However, it is the only medication
that affects the regulation of norepinephine by acting as
a potent inhibitor of the presynaptic norepinerhrine transporter.
It is not associated with an appreciable abuse potential and
is not a controlled substance.
The response to treatment of ADD (ADHD) was dose-dependent
and in open label trials it was suggested that Strattera was
as effective as methylphenidate for the treatment of ADHD.
Dosing of Strattera depends on body weight. Children and adolescents
up to 70 kg body weight should begin with 0.5 mg/kg/day; the
dose should be increased to 1.2 mg/kg/day after a minimum
of 3 days on the initial dose. The maximum dose should be
the lesser of 1.4mg/kg/day or 100 mg/day. Adults and children/adolescents
over 70 kg body weight should begin with 40 mg/day; the dose
should be increased to 80 mg/day after a minimum of 3 days
on the initial dose. After 2 to 4 additional weeks, the dose
may be increased to a maximum of 100 mg/day in patients who
have not reached optimal response.
Strattera is recommended to be administered as a single
daily dose in the am or pm. and with effects lasting until
the next dose. It may be administered with or without food.
Although, some evidence indicates that taking with food decreases
gastrointestinal side effects. Side effects include initial
weight loss, gastrointestinal distress, somnolence, and some
dizziness.
(the following are direct quotes from children in treatment
for ADD (ADHD) with Patricia Quinn, M.D.)
-
"When I take my medicine it's like glue. Before,
my brain was all in pieces but the medicine has stuck
it all together."
-
"Before, I was looking through a door that had
frosted glass but now it is all clear."
-
When I take my medicine for homework, it is like
my teacher is in my head."
-
"I don't feel any different when I take my medicine,
but my report card sure looks different!"
-
"On my medicine I feel calm, without it I'm
in hyperspace."
- "Why can't I take my medicine all the time,
not just for school?"
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