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ESTES PARK, COLO. – Hands down, the most effective treatment for adult attention-deficit/hyperactivity disorder is psychostimulants.
The nonstimulant medications are a second-line alternative with less robust benefits, but they come in quite handy in selected situations, Dr. Robert D. Davies noted at a conference on internal medicine sponsored by the University of Colorado.
Also, a wealth of nonpharmacologic treatments are available. These include mindfulness exercises, cognitive behavioral therapy, life coaching, psychoeducational self-help audio books, and support groups.
"They’re great adjunct treatments, but in and of themselves not great solo treatments," according to Dr. Davies. "There’s an analogy to having poor near vision, so you never learned to read, and then suddenly you get glasses. That’s kind of like getting on medications: You still wouldn’t know how to read, but now you could learn how. So trying the nonpharmacologic interventions will be pretty frustrating for somebody who wants to avoid medications. You can try using those tools to help them with organization and those sorts of things, but it’s usually a huge struggle. Instead, put them on meds, teach them some of those things, and then see if off meds they can maintain those gains," advised Dr. Davies, a psychiatrist at the university.
Dr. Robert D. Davies
A tip on self-help books geared to adults with attention-deficit/hyperactivity disorder (ADHD): "If you have a patient who’s never been able to get through a book in their life, don’t recommend a book that’s going to help them. ADHD folks do better with books on tape." Among the many on the market, Dr. Davies mentioned "Driven to Distraction" by Dr. Edward M. Hallowell and Dr. John J. Ratey as particularly good.
The psychostimulants fall into two categories: methylphenidate formulations and dextroamphetamine formulations. They’re equally effective, with the caveat that 20% of the population doesn’t respond to the methylphenidate drugs; however, they do respond to the dextroamphetamines. It’s a class effect, so when a patient isn’t doing well on a methylphenidate, don’t bother switching to a different methylphenidate drug; move on to a dextroamphetamine formulation.
Only four stimulants are approved by the Food and Drug Administration for adults: Adderal XR (dextroamphetamine/amphetamine), with a 9-hour duration of action and 15- to 30-mg dosage range; Focalin XR (dexmethylphenidate), with an 8- to 12-hour duration of action and dosage range of 20-40 mg; Vyvanse (lisdexamfetamine dimesylate), with a duration of 12 hours and dosing at 30-70 mg; and Concerta (methylphenidate extended-release), with a 12-hour duration of action and dosage range of 18-54 mg.
A history of drug abuse is a consideration in choosing a pharmacologic agent, but it isn’t necessarily a deal breaker in prescribing a stimulant. Some individuals with ADHD used stimulants or cocaine illicitly while students as a form of self-medication to enhance academic performance; they may be reasonable candidates for Concerta or Vyvanse, which have extremely low abuse potential. On the other hand, Dr. Davies recommended against prescribing stimulants for adult ADHD patients with a history of opiate or methamphetamine abuse.
Other situations where stimulant medications are best avoided include patients with medical conditions including heart disease, hypertension, and seizure disorders.
Only one nonstimulant medication is approved in adults: Strattera (atomoxetine). The reduction in ADHD symptoms is roughly 30% less than with stimulants. However, it is a once-daily drug, which is an advantage.
"When I’m treating anxiety or ADHD, especially in adults, a longer-acting drug is better. I always try to get patients away from that on-off phenomenon. That’s a feeling they don’t like," the psychiatrist continued.
Adults with ADHD may need pharmacologic assistance not only during a lengthy workday, but in the evening as well.
Nonstimulants that are sometimes used off-label in adults include Wellbutrin (bupropion), which is approved for children with ADHD. It is about half as effective as a stimulant medication. Effexor (venlafaxine) and Provigil (modafanil) are other nonstimulants used off-label; neither has been well studied in adult ADHD, according to Dr. Davies.
Adults with ADHD don’t develop tolerance to stimulant medications, unlike amphetamine abusers. Asked if there is an upper age limit for the use of psychostimulants in treating ADHD, the psychiatrist replied no.
"My oldest patient is 75 and I’ve been treating him for the last 15 years," he added.
Dr. Davies reported having no financial conflicts.