ORLANDO – Start with a long-acting stimulant for treatment of attention-deficit hyperactivity disorder for most patients, increase the dose before adding a short-acting drug, and monitor response with a rating scale, Dr. Peter S. Jensen advised at a psychopharmacology congress sponsored by the Neuroscience Education Institute.
Begin with intensive treatment, because studies show it can make a difference up to 2 years out, Dr. Jensen said. “We now have studies of the stimulants–the methylphenidate preparations, the amphetamine, dextroamphetamine, and atomoxetine–showing sustained benefit through 12 months and up to 2 years.”
The symptom profile for attention-deficit hyperactivity disorder (ADHD) evolves with age. Hyperactivity, impulsivity, aggression, distractibility, a low frustration tolerance, and difficulty with establishing routines are among the childhood symptoms. “Individuals with predominantly inattentive symptoms are more likely to be overlooked,” said Dr. Jensen, director, Center for the Advancement of Children's Mental Health, department of child psychiatry, Columbia University, New York.
Adolescents with ADHD are often easily distracted/inattentive, easily bored, impatient, and emotionally immature, compared with peers. “ADHD–the full syndrome–is rarely seen in adults. So many kids initially diagnosed with the full syndrome lose a lot of the hyperactivity and impulsivity as they get older,” Dr. Jensen said. “What remains? Inattention (J. Clin. Psychol. 2005;61:535–47).
Monitor treatment response with age-appropriate rating scales, Dr. Jensen suggested. Examples include the Early Childhood Attention Deficit Disorder Evaluation scale for preschool children; the Child Behavior Checklist for school-age children; and the Adolescent Symptom Inventory for adolescents. In addition, the Brown Attention Deficit Disorder scales are useful for patients who are primarily inattentive.
“If we don't use these, we are shooting from the hip. We get parent ratings and teacher ratings with these and it's great documentation,” Dr. Jensen said. “I graph them and show them to families–they love them.”
Stimulant medications can be effective for both motor and attention symptoms of ADHD. “Avoid dosing late in day, because of risk of insomnia. Children who are not growing or gaining weight should stop treatment, at least temporarily,” Dr. Jensen said. “If a kid is not in terrible trouble on the weekends, you might consider [drug] holidays.”
The stimulant methylphenidate is available in various long-acting formulations. For example, the methylphenidate transdermal system (Daytrana, Shire) was approved by the Food and Drug Administration in April 2006. “I have not used it yet, but it's a very interesting strategy,” Dr. Jensen said. “You can remove the patch if you want to–you cannot unswallow a pill. It is also good option for kids who cannot swallow a pill.”
A disadvantage is its relatively large size, which increases with the dose.
Onset of action is gradual and can take up to 2 hours after application. Peak administration typically takes 7–9 hours. A single patch can provide all-day efficacy (J. Am. Acad. Child Adolesc. Psychiatry 2005;44:522–9).
Duration of any methylphenidate should be balanced against the potential for side effects, most commonly, impaired sleep and appetite, Dr. Jensen said. “Except for very young children, start with long-acting. What I would urge you not to do is start with long-acting and add short-acting.”
Not all methylphenidate is created equal. “A lot of these medications will have different percentages of short-acting beads and long-acting beads,” Dr. Jensen said. “Even though it is the same molecule, you will see different peaks. How the body responds to these slopes can lead to significant person-to-person variations in response and side effects.”
He said he generally goes to the methylphenidate products sooner because they have less potential for abuse than amphetamines. Amphetamines, however, “may have more of a punch of action for efficacy versus methylphenidate.”
A new lysine prodrug of d-amphetamine is in development. It is designed for slower release onto the receptor and potentially less stimulation and abuse potential. “The company has an approvable letter from the FDA,” Dr. Jensen said. “Will it be as effective with lower side effects? That remains to be seen.”