Attention-Deficit Hyperactivity Disorder (ADHD)

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Medications

Parent involvement in medication treatment is extremely important to ensure the child takes the required doses on time, to monitor for side effects and effectiveness of the drug, and to enlist the school's help when medication needs to be taken during school hours. Medication is the first-line treatment for ADHD and includes the following types of drugs:

• Stimulants (including amphetamines)
  
• Non-stimulants
  
• Antidepressants
  
• Antihypertensives
  
• Mood stabilizers
  
• Neuroleptic drugs
  

Stimulants

Stimulants that decrease impulsivity and hyperactivity and increase attention are commonly used to treat ADHD. These medications are used with careful monitoring and compliance and may improve symptoms in approximately 70–90% of cases. In children with ADHD, an improvement in symptoms often leads to an improvement in self-esteem.

These drugs increase the levels of the neurotransmitters dopamine, norepinephrine, and serotonin. Higher levels of dopamine are thought to reduce hyperactivity, while an increase in norepinephrine improves attention. The effects of low serotonin levels in children with ADHD are not fully understood.

The following stimulants are used to treat ADHD:

• Methylphenidate (Ritalin®, Concerta®, Methylin®)
  
• Dextroamphetamine (Dexedrine®, Dextrostat®)
  
• Amphetamine: combined dextroamphetamine and levoamphetamine (Adderall®)
  
• Lisdexamfetamine (Vyvanse®)
  

Methylphenidate (Ritalin®, Concerta®, Methylin®) is the most widely studied ADHD drug. Ritalin is available as a once daily preparation.

Dextroamphetamine (Dexedrine®, Dextrostat®) is available in long-lasting doses. The combination of dextroamphetamine and levoamphetamine (Adderall®), two amphetamines, is shown to be effective, though it is not prescribed as often as methylphenidate, and is available as a once daily preparation.

In October of 2005, the Food and Drug Administration (FDA) withdrew approval for magnesium pemoline (Cylert®), a drug that had been used rarely as a second-line medication to treat ADHD. This medication carries a high risk for liver failure. Generic versions have remained on the market to allow physicians to find alternative treatments for their patients. Magnesium pemoline has been associated with 13 deaths due to liver failure since its introduction in 1975, and liver function levels must be monitored every 2 weeks during treatment.

In February of 2006, an FDA advisory panel recommended the most serious warning label (i.e., "black box" safety warning) for these ADHD medications, due to an increased risk for severe cardiovascular problems in adults and children. Studies have shown an increased risk for heart attack, stroke, high blood pressure (hypertension), and abnormal heart beat (arrhythmia).

Common side effects of stimulants include the following:

• Emotional oversensitivity, crying easily
  
• Headaches
  
• Irritability
  
• Loss of appetite (anorexia)
  
• Poor appetite and weight loss
  

Stimulants are usually well tolerated by children and adults. Though they may slow the growth rate in children, they do not seem to affect their eventual height. Using the summer as a "drug holiday" (no medication) may help normalize growth.

Tics may occur temporarily in about 9% of children treated with stimulants and may be chronic in about 1%. Careful monitoring is necessary to detect the emergence and/or worsening of tics while using stimulant medication.

Children and adults with high blood pressure (hypertension) should take the smallest dose possible, as amphetamines in general and magnesium pemoline in particular may worsen hypertension. Blood pressure should be carefully monitored throughout treatment.

Although drug abuse does not usually occur with properly monitored prescribed stimulants, there may be a risk for abuse in patients who also suffer from conduct disorder and those who have a preexisting substance dependency. If the risk among the patient's peers or family is high, it may be preferable to choose another class of drug.

Currently, there is no evidence to show that these drugs cause birth defects or problems for nursing babies; however, pregnant women are advised to discuss this with their physician. Women may be advised to avoid stimulants while nursing, since the stimulants may be excreted in breast milk.

Non-Stimulants

Atomoxetine HCl (Strattera®) may be used to treat ADHD in adults and children. Strattera is a non-stimulant that increases levels of the neurotransmitter norepinephrine. It is available in oral capsule form in several dosage strengths. Strattera usually is taken once or twice a day, with or without food.

Strattera should not be used in patients who take monoamine oxidase inhibitors (MAOI; e.g., Nardil®, Parnate®) or in patients with narrow angle glaucoma. It should be used with caution in patients with liver or kidney disease, certain heart conditions (e.g., tachycardia), high blood pressure (hypertension), or low blood pressure (hypotension). Strattera should be discontinued in patients who exhibit symptoms of liver damage (e.g., itchy skin, jaundice, dark urine).

Women who are pregnant, planning to become pregnant, or breastfeeding, should inform their physician before taking Strattera.

Side effects in children may include the following:

• Abdominal pain
• Decreased appetite
• Dizziness
• Fatigue (tiredness)
• Headache
• Mood swings
• Nausea and vomiting

In adults, Strattera may cause the following:

• Constipation
  
• Decreased appetite
  
• Difficult urination
  
• Dizziness
  
• Dry mouth
  
• Fatigue
  
• Headache
  
• Insomnia
  
• Nausea
  
• Reproductive system disorders such as erectile dysfunction, prostatitis, and menstrual irregularities

Antidepressants

Antidepressant medications affect many of the same neurotransmitter levels as stimulants. Fewer studies have been performed regarding the use of these drugs to treat ADHD. The following antidepressants are sometimes used to treat ADHD:

• Tricyclic antidepressants (e.g., nortriptyline, Tofranil®, Norpramine®)
  
• Bupropion (e.g., Wellbutrin®)
  
• Venlafaxine (e.g., Effexor® XR)
  

Tricyclics (e.g., amitriptyline, clomipramine) have shown some effectiveness, but more research is needed. Children who take tricyclics may have a greater risk for heart problems than adults. Patients taking tricyclics must be monitored for possible cardiac side effects, such as rapid heartbeat and low blood pressure (hypotension).

Bupropion (Wellbutrin®) stimulates the effects of dopamine and may reduce hyperactivity and aggressiveness, which makes it especially useful for children. In adults, it is typically less effective than stimulant medication.

Venlafaxine (Effexor®) affects the levels of both serotonin and norepinephrine and may be best suited for reducing attention problems. Some studies have found it to be effective in adults.

Side effects commonly associated with antidepressants include the following:

• Constipation
  
• Diarrhea
  
• Dizziness
  
• Dry mouth
  
• Headache
  
• Nausea
  

Antihypertensives

The Food and Drug Administration (FDA) has not approved the use of antihypertensives for ADHD. Four children have died while taking a combination of the stimulant methylphenidate (Ritalin®) and the antihypertensive clonidine (Catapres®), but the cause of these deaths is unclear.

Some evidence suggests that the sedation induced by antihypertensives like clonidine (Catapres®) and guanfacine (Tenex®) helps reduce symptoms of ADHD when combined with stimulants. Antihypertensives also may be helpful in patients with ADHD and tics.

Antihypertensives may be used as an alternative to stimulant medications, especially in the 30% of children who cannot tolerate stimulants, and in children with conduct problems. However, antihypertensives may not improve attention deficit or distractibility.

The physician should perform a thorough cardiovascular history and examination before prescribing an antihypertensive. These drugs should be used carefully and monitored with blood pressure checks and heart rate analyses in all patients.

The most common side effects of antihypertensives include the following:

• Drowsiness
  
• Dry mouth
  
• Headache
  
• Mildly low blood pressure
  
• Nausea
  

When discontinuing these drugs, the dosage is tapered slowly. Abrupt discontinuation can lead to headache, agitation, and elevated pulse rate and blood pressure.

Mood Stabilizers

Antiepileptic drugs such as carbamazepine (Tegretol®, Epital®) and gabapentin (Neurontin®) are not FDA-approved to treat ADHD. These drugs can effectively treat symptoms of bipolar disorder and may be used in people with ADHD who experience mood swings. However, gabapentin may actually worsen oppositional behavior in some ADHD cases.

Neuroleptics

Neuroleptics (also called conventional antipsychotics) such as halperidol (Haldol®) may be used to treat tic disorders, schizophrenia, and rarely, ADHD with tic disorder. These drugs are associated with significant adverse side effects, including tardive dyskinesia, a serious neurological disease that causes disturbing, involuntary muscle movement. Use of neuroleptic drugs for ADHD is unsupported, has not been studied formally, and is potentially harmful.

Attention-Deficit Hyperactivity Disorder (ADHD), Medications reprinted with permission from mentalhealthchannel.net
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