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Update on Medications Used in The Treatment of ADHD

By Patricia Quinn, M.D.

Over the last decade, many advances have been made in the delivery of the medications to treat AD/HD in children and adults.  As a result, several new medications have been approved that make the treatment of AD/HD both easier and more effective. These newer medications are all longer-acting preparations and offer a variety of formulations and delivery systems. These once-a-day preparations provide the individual with AD/HD a means of reducing symptoms throughout the day and into the early evening, while eliminating the need for a multiple dose regime that was difficult for those with AD/HD to remember. In addition, longer-acting medications have fewer side effects, particularly the mood swings, related to multiple daily doses.

AD/HD have been shown to affect all aspects of a person’s daily functioning including job and academic performance, social/romantic relationships, and self-esteem. AD/HD even affects sleep with many individuals reporting difficulty falling asleep, sleeping through the night, waking-up the next morning or remaining alert throughout the day. Research (including hundreds of studies) and clinical experience have shown that stimulant medications are the most effective first-line treatment for reducing the core symptoms of AD/HD. Medications combined with other therapies can significantly affect overall functioning and improve quality of life for those suffering from the disorder.

If you are an adult or the parent of a child with AD/HD (either newly diagnosed or currently being treated with a short-acting stimulant or another medication) and feel that a longer-acting medication would help to better address your symptoms, you are urged to consult a physician to discuss the medical treatment of AD/HD and the benefits you could expect from such treatment.

These newer formulations are all considerably more expensive that older versions like Ritalin and Dexedrine and their generic equivalents. However, it should be noted that many of the pharmaceutical companies that manufacture these products have Patient Assistance Programs (PAP) for those who cannot afford these more expensive formulations.

Stimulant Medications

Methylphenidate based products (Ritalin and RitalinSR, RitalinLA,  Methylin and MethylinER, Concerta,  Metadate and MetadateCD , Focalin and  Focalin XR,  Daytrana)

For a number of years, methylphenidate was available only as Ritalin with a duration of action (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 , Methylin ER, Ritalin LA, Focalin XR, and Daytrana) that require only once daily dosing to address AD/HD symptoms throughout the day. These products use different delivery systems (including the patch technology of Daytrana) 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.

Amphetamine-Based Products
(Dexedrine and Dexedrine Spansules,  Adderall  and AdderallXR ,  and Vyvanse) 

All of these medications 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 AD/HD, but is not prescribed as frequently.  Adderall and AdderallXR are the trade names for a generic compound of mixed amphetamine salts (three forms of d-amphetamine and one of l-amphetamine). Adderall XR has a much longer duration of action (e.g. 10-12 hours) and will available soon as an ever longer-acting formulation. Vyvanse is a newer formulation or prodrug containing a form of dexamphetamine. A prodrug is a therapeutically inactive precursor of a drug that is converted to the active form by a metabolic process that takes place in the body after it is ingested. Vyvanse is probably the longest-acting formulation of a stimulant on the market to date and has greatly reduced abuse potential since the drug is not active until it is broken down in the body.
           
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 reducing symptoms for many hours without the feeling that medication effects are starting and stopping throughout the day. This longer-duration may help the student address not only symptoms causing academic difficulties, but also those that can affect social and daily-living activities of adults with AD/HD. Stimulants can cause mild increases in pulse and blood pressure and should not be used by individuals with known cardiac disorders or a family history of cardiac symptoms. Please consult your physician regarding these potentially lethal complications before starting on a stimulant.

Use during Pregnancy

To date, there have been no controlled studies looking at the effects of stimulant use during pregnancy. There have been a few animal studies reporting cardiac defects at high doses of amphetamines and individual case reports of use of both amphetamines and methylphenidate by mothers during their pregnancies without harm to the fetus. However, at this time, looking at all the available evidence, the prevailing recommendations is that stimulants should be used during pregnancy only when the potential benefits to the mother outweigh any risk to the fetus. Therefore, a woman considering pregnancy should discuss her continued medication use with her prescribing physician.

Non-Stimulant Medications

Atomoxetine (Strattera)

Strattera is a selective norepinephrine reuptaker inhibitor, which is indicated for the treatment of ADHD in children, adolescents, and adults. 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. Strattera is recommended to be administered as a single daily dose in the am or pm 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. Recent studies have found this medication effective in reducing both the symptoms of AD/HD and coexisting anxiety.

Clonidine and guanfacine (Catapres and Tenex)

Clonidine and guanfacine, alpha-2A adrenergic agonists, have also been used off-label in the management of children with attention-deficit/hyperactivity disorder (ADHD) for more than a decade. Guanfacine is preferred by many for its longer duration of action. A new extended-release formulation of guanfacine is currently under review by the Food and Drug Administration (FDA) specifically for the treatment of ADHD in children between 6 and 17 years of age.

 

The following table lists the current medications used to treat AD/HD, their relative duration of action, and the website (if available) to obtain more information about them.

 

Immediate-release Drugs: Description and Duration

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)

Longer-acting Drugs: Description, Duration and Websites

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) www.adderallxr.com 8-12 hours
Metadate® CD (methylphenidate formulation designed to mimic BID) 4-8 hours
Concerta® (methylphenidate formulated to mimic TID duration) www.concerta360.com 10-12 hours
Dexedrine Spansules (longer-acting amphetamine) 8-10 hours

Daytrana Patch (methylphenidate deliverd in a patch that can be worn for up to 9 hrs) www.daytrana.com

10-12 hours
Vyvanse (a prodrug that is activiated in the body and contains dexamphetamine) www.vyvanse.com 12-14 hours

Strattera  (non-stimulant atomoxetine) www.strattera.com

24 hours

 

What children with ADD (ADHD) say about their medication:

(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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