Efficacy and tolerability of ADHD medications in a clinical practice
Jill Miller-HornJoseph KaleyiasIgnacio ValenciaJoseph J. MelvinDivya S. KhuranaH. Huntley HardisonHarold G. MarksAgustín LegidoSanjeev V. Kothare
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Randomized controlled trials have shown that stimulants reduce symptoms of impulsivity and hyperactivity in children with attention deficit/hyperactivity disorder (ADHD); however, these rigid protocols show no advantage of one medication over another. Our study examined the question of differential efficacy and tolerability of five medications used for ADHD, in the open-label setting of our outpatient child neurology clinic. This retrospective study identified 137 children and adolescents (109 boys and 28 girls), with a mean age of 10 years (range 4 to 19 years) treated for ADHD. Treatment options were amphetamine/dextroamphetamine extended release (adderall XR) in 19.0%, amphetamine/dextroamphetamine (adderall), osmotic controlled-released (OROS) formulation of methylphenidate (OROS-MPH, concerta) in 29.2%, atomoxetine (strattera) in 21.9% and methylphenidate standard release (MPH) in 16.8%. Global effectiveness was assessed for each medication. Overall, 78% of patients improved with medication, with no significant statistical difference in efficacy among the five medications. Side effects included decreased appetite (14.6%), insomnia (10.2%), headaches (7.3%), and tics (3.7%). The only difference in side effects was with atomoxetine showing a significantly lower incidence of headaches than amphetamine/dextroamphetamine XR, amphetamine/dextroamphetamine or OROS-MPH. In conclusion, our results in the open-label setting were comparable to those found in randomized controlled trials; the medications we examined were equally effective with minimal differences in side effect profiles.Keywords:
Dextroamphetamine
Tolerability
Zonisamide
Stimulant
Pharmacotherapy of attention-deficit/hyperactivity disorder in adulthood includes psychostimulants, antidepressants and atomoxetine, the first of them being considered the first choice. Methylphenidate efficacy has been demonstrated in adults when higher doses were used, in a proportionate similar way to what has been described in children. Methylphenidate profile of adverse events, including cardiovascular ones, seems to be safe. Key-words Attention deficit hyperactivity disorder, adults, treatment, psychostimulants, antidepressants, comorbidities.
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Researchers at Utrecht University, The Netherlands, and University “Roma Tre,” Rome, Italy, studied the neural substrates of the previously identified social play-suppressant effects of methylphenidate (MPH) and atomoxetine, drugs widely used for the treatment of attention-deficit hyperactivity disorder (ADHD).
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This study documented the prescribing patterns of methylphenidate and atomoxetine among patients aged 3 to 18 in Taiwan diagnosed with attention deficit hyperactivity disorder (ADHD) between 2004 and 2017. Initial treatment for ADHD, the time between the first diagnosis and the first prescription, and medication-switching patterns were investigated. The final cohort consisted of 256,882 patients, and 147,210 (57.3%) of them received medication treatment. Most of the patients (98.2%) received methylphenidate. Atomoxetine use increased from 0.1% in 2007 to 5.5% in 2017. The median time between the ADHD diagnosis and the first prescription was 21 days (IQR: 0–212 days). In patients who initiated methylphenidate, 12,406 (8.4%) patients switched to atomoxetine; 850 (31.3%) of the children began with atomoxetine and switched to methylphenidate. In conclusion, methylphenidate was the predominant treatment for ADHD in 2004–2017. However, the prevalence of pharmacotherapy for ADHD was relatively low. Further investigation on the reasons behind this pattern is recommended.
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Purpose: To determine the prescribing pattern of methylphenidate and atomoxetine to patients with Attention-Deficit/Hyperactivity Disorder (ADHD) in South Africa.Methods: A retrospective, cross-sectional pharmacoepidemiological study was conducted based on the data from a medical aid administrator in South Africa for 2011. All records for ADHD patients who received one or more prescriptions for methylphenidate and/or atomoxetine (ATC Code N06BA) were extracted for analysis.Results: A total of 455 patients (mean age: 16.5 ± 11.56 yr) received 1653 prescriptions for methylphenidate and/or atomoxetine at a total cost of South African Rand 554,915.84 (US dollar 1.0 = Rand 6.76). A majority of these patients (70.34 %) were males and 21.10 % were older than 18 yr (25.76 % of females and 19.81 % of males). About a third of the prescriptions (30.44 %) were dispensed to children younger than 12 years while 25.88 % were dispensed to adolescents (12 to 18 years). Most prescriptions (92.01 %) were for methylphenidate while atomoxetine accounted for 7.99 % of the prescription. A majority of the prescriptions for methylphenidate (47.86 %) were for children younger than 12 yr, and most prescriptions for atomoxetine (52.27 %) were for adolescents.Conclusion: Methylphenidate is the mainstay in the treatment of ADHD in South Africa, with atomoxetine prescribed more often to older patients. Drug use is rational and dosages are within the recommended dosage ranges. As expected, older patients are receiving treatment for ADHD.Keywords: Methylphenidate, Atomoxetine, Attention-Deficit/Hyperactivity disorder, Pharmacoepidemiology
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The most common class of drugs used to treat Attention Deficit-Hyperactivity Disorder (ADHD) are the central nervous stimulants. These drugs stimulate specific areas of the central nervous system and aim to reverse the symptoms of ADHD. Medication for ADHD can be divided into stimulants such as methylphenidate, dexamphetamine, and lisdex amphetaminedimesylate, and non-stimulants such as atomoxetine.
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Methylphenidate (Ritalin) is the drug of choice for the treatment of Attention Deficit Hyperactivity Disorder (ADHD). Methylphenidate has been rigorously studied and found to be a safe and effective drug. However, there is a need for pharmacological alternatives since there are patients and therapists who are reluctant to use the drug. In some cases it is ineffective, others suffer from intolerable side effects and still others need treatment extended for the entire day. Recently, new pharmacological agents have been introduced for use in Israel. This article discusses the use of these new psychostimulants as well as other non-psychostimulant options. One of the new psychostimulants is Concerta, a very long acting methylphenidate preparation, that has been shown to be very effective. Adderall, a mixture of amphetamine salts, and Dexedrine (dexamphetamine) are also widely used. This article also presents data on an older psychostimulant, Cylert, Nitan (pemoline), prescribed until recently as a major alternative for Ritalin but, at present, it is rarely used because of its hepatotoxicity. Strattera (atomoxetine), a new non-stimulant drug, is a selective noradrenaline reuptake inhibitor that is a promising therapeutic option for children with ADHD. In summary, it is encouraging that there are multiple pharmacological options for treating children with ADHD. There is no one drug for all children and this is particularly important for children with do not respond to methylphenidate. Last, but not least, the mere fact that the new drugs are not called Ritalin, may play an important role in reducing the irrational opposition to the pharmacological treatment of ADHD.
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This study examined augmenting atomoxetine with extended-release methylphenidate in children whose attention-deficit/hyperactivity disorder (ADHD) previously failed to respond adequately to stimulant medication.Children with ADHD and prior stimulant treatment (N = 25) received atomoxetine (1.2 mg/kg/day) plus placebo. After 4 weeks, patients who were responders (n = 4) were continued on atomoxetine/placebo while remaining patients were randomly assigned to either methylphenidate (ATX/MPH) (1.1 mg/kg/day) or placebo augmentation (ATX/PB) for another 6 weeks. Patients and sites were blind to timing of active augmentation. Safety measures included vital signs, weight, and adverse events. Efficacy was assessed by ADHD rating scales.Categorical increases in vital signs occurred for 5 patients (3 patients in ATX/MPH, 2 patients in ATX/PBO). Sixteen percent discontinued the study due to AE, but no difference between augmentation groups. Atomoxetine treatment was efficacious on outcome measures (P
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Oppositional defiant disorder (ODD) is frequently comorbid with attention deficit hyperactivity disorder (ADHD) and is associated with substantial functional impairments. Methylphenidate and atomoxetine are well-established drugs for the management of ADHD. Some studies from Western countries have reported these drugs to be effective in the management of ODD comorbid with ADHD. This study aimed to assess if methylphenidate and atomoxetine are efficacious in treating Indian children with ODD comorbid with ADHD.In this prospective, open-label study, 37 patients of age 6-14 years with a diagnosis of ODD comorbid with ADHD randomly received either methylphenidate (dose 0.2-1 mg/kg/day) or atomoxetine (dose 0.5-1.2 mg/kg/day) for 8 weeks. Improvements in ADHD and ODD symptoms were assessed using Vanderbilt ADHD diagnostic parent rating scale (VADPRS).At 8 weeks, there were statistically significant improvements in both ADHD and ODD symptoms in both methylphenidate and atomoxetine groups, as per VADPRS. The improvements produced and tolerability was comparable in the two groups. 80% of the patients from methylphenidate group and 64.3% patients from atomoxetine group ceased to fulfill the criteria for the presence of ODD at 8 weeks.Methylphenidate and atomoxetine are effective in the treatment of ODD comorbid with ADHD in short duration.
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