ADHD Treatment Medication Robin K. Blitz, MD. ADHD DIAGNOSTIC CLINIC Week 2

Transcription

1 ADHD Treatment Medication Robin K. Blitz, MD ADHD DIAGNOSTIC CLINIC Week 2

2 Treatment Should you treat ADHD? Effective treatment for ADHD is imperative! ADHD is one of the MOST COMMON disorders treated by pediatricians and psychiatrists Major clinical and public health problem Safe and effective treatment is available Benefits of treatment outweigh risk

3 Treatment Modalities for ADHD Educational Interventions Medical Interventions Psychosocial Interventions ADHD Practice Parameters. JAACAP. 1997;36:85S.

4 Multimodal Treatment Study of Children with ADHD (MTA) 14-month, multicenter, randomized, controlled trial N = 579 children, age 7 to 9 years, ADHD combined Treatment arms: Medication management only MPH TID, adjusted for best dose, other drugs if necessary; algorithmic dose adjustments; general advice and readings; case management by pharmacotherapist Intensive behavioral treatment only parent training; structured teacher consultation; 8-week, fulltime, summer treatment program; 12 weeks of half-time, classroom, behavioral specialist; case management by therapist/consultant Medication management + intensive behavioral treatment Community-based care after assessment by investigators, parents could seek community care (roughly two-thirds received medication chosen by physician) MTA Cooperative Study Group. Arch Gen Psychiatry. 1999;56:1073.

5 MTA Study Results All Treatments Led to Improvement in Core ADHD Symptoms Medication Management Alone Medication Management + Behavioral Treatment Nearly Equal Effectiveness and Superior to Both: Behavioral Treatment Alone Community Based Treatment MTA Cooperative Study Group. Arch Gen Psychiatry. 1999;56:1073.

6 Are Stimulants safe and effective in ADHD? AMA Council on Scientific Affairs NIH Consensus Development Conference AACAP AAP

7 Psychostimulants Improve Inattention Hyperactivity Primary Impulsivity Classroom Behavior Social Interactions Secondary Impulsive Aggression Academic Performance Noncompliance

8 = NT = neurotransmitter; dopamine/norepinephrine AMPH = amphetamine MPH=methylphenidate Stimulants Proposed Mechanism of Action AMP H Presynaptic Neuron Storage Vesicle Neurotransmitter Transporter NT Transporter (reuptake pump) Neurotransmitter Output Postsynaptic Neuron Adapted from Wilens & Spencer. Child Adolesc Psych Clin N Am 2000;9:573.

9 Stimulants for the Treatment of ADHD Generic Name Hours active 4 hours 4-8 hours > 8 hours Amphetamine mixed salts Adderall (low dose) Adderall (high dose) Adderall XR Vyvanse Dextro-amphetamine Dexedrine Dextrostat Dexedrine spansules Methylphenidate Ritalin Ritalin-SR Concerta Methylin Metadate-ER Metadate-CD Focalin Methylin-ER Ritalin-LA Focalin-XR Daytrana

10 Benefit-Risk Ratio and Efficacy of Stimulants Very favorable benefit-risk ratio rapid, dramatic results low risk of long-term side effects Approximately 70% of patients with ADHD will show a positive response on the first trial of any one stimulant medication If two different stimulant medications are tried, the response rate increases to ~90% Greenhill. Child Adolesc Psychiatr Clin North Am. 1995;4:123; Spencer et al. JAACAP. 1996;35:409; Goldman et al. JAMA. 1998;279:1100.

11 Other medications used in the Treatment of ADHD Tricyclic antidepressants Alpha 2-adrenergic agonists Norepinephrine reuptake inhibitor Atypical Antidepressants Imipramine (Tofranil) Nortryptiline (Pamelor) Clonidine, Catapres TTS Guanfacine (tenex), Guanfacine-XR (Intuniv) Atomoxetine (Strattera) Buproprion (Wellbutrin) Buproprion SR (Wellbutrin SR) Buproprion XL (Wellbutrin XL)

12 What if you don t treat?

13 Impact of Untreated & Under-treated ADHD Healthcare System School Society Family Occupation 50% in bike accidents 1 33% in ER visits x more motor vehicle crashes % expelled 6 35% drop out 6 Substance use disorders: 2 x risk 8 Earlier onset 9 Less likely to quit in adulthood x > parental divorce or separation 11, x > sibling fights 13 Lower occupational status 7 > parental absenteeism and productivity 14 1DiScala et al, Liebson et al, NHTSA, Barkley et al, 1993, Barkley et al, Mannuzza et al, Biederman et al, Pomerleau et al, Wilens et al, Barkley et al, Brown & Pacini, Mash & Johnston, Noe et al, 1999.