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ADHD medications

The medications for the treatment of ADHD fall into three basic categories - stimulants, so-called 2-adrenergic agents, and "neither." These medicines offer significant benefits to children with ADHD symptoms, but as with all medicines, it is important that the correct drug or drugs be used for the symptoms that are problematic, and side effects must be watched for and managed.

Stimulants

There are a number of stimulant class medications for ADHD treatment on the market now. Stimulant drugs are used when

• either the child's academic performance is below expectation based on his or her learning abilities
• or the child's self-image is suffering because he or she is getting in trouble often and symptoms of attention deficit, impulsivity, or hyperactivity appear to be contributing factors

Stimulant medication dosing has to be done with attention paid to the duration of action of the medicine. Longer- and shorter-acting stimulants can be combined to avoid rebounding and to better cover the demands of the school day. Some of the available preparations:

• Vyvanse® is a recent drug development. It is a "prodrug" in the amphetamine family. It is designed to be activated by the liver after ingestion, giving a fairly constant level of action throughout the day. It lasts up to 12 hours.
• Adderall XR® (mixed ampthetamine salts) lasts about 10 hours; plain Adderall lasts about 6 hours
• dextroamphetamine (Dexedrine®) lasts 4-6 hours
• Dexedrine Spansules®, also in the amphetamine family, last 6-8 hours
• Concerta® is a popular timed-release methyphenidate; lasts 12 hours.
• Methylphenidate (Methylin® or Ritalin®) is shorter acting with a duration of 3-4 hours.
• Metadate ER® or Ritalin SR®, last about 5-7 hours
• Metadate CD® is a different dosage system from the older ER version ("Constant Dose" vs "Extended Release")
• Focalin XR® (an isomeric form of methylphenidate) lasts about 10 hours

Another goal in treatment is to minimize side effects of weight loss and slower growth due to appetite suppression. Give stimulants after breakfast and lunch or a snack. As a general rule we try to minimize weekend and late afternoon dosing, and we encourage nutritious and high-calorie evening or bedtime snacks.

Sleep disturbances are another area of possible concern. When stimulants wear off in the evening, there can be rebound effects of restlessness. These can often be minimized or avoided by using the smallest dose possible in the late afternoon. Clonidine (which tends to make children sleepy) can be added to avoid sleep disturbances due to rebounding at bedtime.

The initial dose probably should be started on Saturday during a trial of medication. This way, parents can monitor the effects directly. I find parents like to know from personal observation what effects the medications have on their children. This is not only helpful to the doctor in tailoring the therapy, but proves to the parents that their child is not somehow transformed by the medicine into someone strange. If there are to be two doses in the day, it is best to overlap the next dose with the end of the effect of the preceding dose.

Medication has to be chosen with a mind toward other problems the child may have. Stimulants may worsen anxiety in patients with obsessive-compulsive disorder. They can however help some children with ADHD and mental retardation. Children with autism and hyperactivity may benefit from stimulants. Seizures are not increased by stimulants in most children with epilepsy.

Tics are not necessarily a contraindication to stimulant medication use. Although stimulants may exacerbate tics in 33%-50% of children with tics, current medical thinking is that there is no evidence that they ultimately change the natural history of tics or cause Tourette syndrome.

2-Adrenergic Agonists

This class of drugs includes clonidine (Catapres®) and guanfacine (Tenex®). Clonidine is available in tablet form or transdermal patch, guanfacine as a tablet. They are effective at treating impulsivity and hyperactivity but not distractibility and shortened attention span. They are also useful in treating tics and sleep disorders in children, but they should not be prescribed for inattention and distractibility.

These drugs have significant side effects of sleepiness and lowered blood pressure, but these can be managed by careful and gradual changes in dosage up to the effective level. This will avoid sleepiness and significant low blood pressure (hypotension). These drugs must be tapered off when stopping medication to avoid significant rebound high blood pressure (hypertension). Sleepiness can be reduced by giving clonidine tablets in frequent, small doses. Also, clonidine and guanfacine should be started at bedtime.

Clonidine and guanfacine take effect much more slowly than stimulants, which work immediately. The full effect of clonidine and guanfacine on impulsivity and hyperactivity may not be seen for 4-5 weeks. Remember that these medications have little effect on distractibility or shortened attention span - that has to be addressed by the stimulant medications.

Atomoxetine and other agents

Strattera® (atomoxetine) is a non-stimulant medication that is not a controlled substance, as there is no abuse potential. It has a very good "side effect profile," i.e., a low incidence of side effects. It does not seem to worsen anxiety in children with ADHD and anxiety. Unfortunately, only a minority of children respond to atomoxetine - it either works, or it does not. Atomoxetine is given every day of the week, not just school days, and requires 2-4 weeks to reach full effect.

Several other agents have been used in the treatment of ADHD. These include tricyclic antidepressants (used for children with ADHD plus other symptoms such as aggression, anxiety, depression, bedwetting, or migraine headaches) and bupropion, an antidepressant. Neither are "first line" drugs for ADHD.

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