Why, For Whom and How?
You have assessed both Nathan and his father and see them again at a follow-up visit. Since ADHD is affecting their daily functioning, you are considering drug treatment for them. What are the available options? Where to begin? Is the treatment different for children and adults? How can you sort out everything the parents have heard and read in the media?
You remind the family that ADHD is a neurobiological disorder that causes chronic self-regulation problems. Prescribing medication is part of a multimodal approach (see Table 1) primarily composed of promoting a healthy lifestyle to maintain good brain function.1,2 Understanding ADHD helps people use coping strategies to reduce their functional impairments (see the articles “ADHD: Tips and Tricks for Young People” and “ADHD: Tips and Tricks for Adults” in this special edition). When residual symptoms continue to have a negative effect, specific drug therapy must be considered.
Dr. Annick Vincent, psychiatrist, practices at Clinique Focus, affiliated with the Centre médical l’Hêtrière, in Saint-Augustin-de-Desmaures. Dr. Michel Sirois, family physician. practises in the family medicine group GMF-Centre medical l’Hêtrière, and at Clinique Focus.
Expectations must be clearly defined because there is no miracle pill! (“Pills don’t build skills!” recalled Dr. Margaret Weiss at the international French-language conference on ADHD held in Quebec City in 2012.) Just as reading glasses are designed to help people to focus and pick out words, not to teach them to read, a well-adjusted drug does not cure ADHD but relieves symptoms, improves functioning and enables patients to tap into their full potential.3
During your last appointment with Nathan and his father, you noticed symptoms, functional impacts and compensatory strategies (see the article “In-Office Assessment of ADHD: Step-by-Step Approach” in this special edition). You opted for drug treatment, knowing that the clinical response will not confirm a diagnosis of ADHD.
There is no maximum age to initiate treatment as long as the patient’s physical condition allows it. The recommended minimum age is 6 years. Given the few existing studies on risks in utero and in infants, it is best for women to cease this medication during pregnancy and breastfeeding.4
Before starting, physicians should ensure that patients have no pre-existing problems that could decompensate during treatment. Specialist advice may be indicated in some complex cases (see the chapters in the Canadian ADHD Practice Guidelines on co-morbid disorders, pharmacological treatment and cardiovascular risks).2
Pharmacotherapy for ADHD is part of a multimodal and individualized approach. It is recommended to start with an extended-release psychostimulant.
You explain the available options and mention that the drugs approved for the treatment of ADHD have shown significant clinical efficacy compared with placebo. Their safety profile is also good. You add that each patient’s clinical response is different and that it is not possible to predict which drug will be more effective in relation to the type or severity of the symptoms.
You inform the family that ADHD medications include methylphenidate-based and amphetamine-based psychostimulants and non-stimulants. These products all promote the neurotransmission of dopamine and-or norepinephrine. They each have different mechanisms of action and release. Methylphenidate and amphetamines mainly act as dopamine reuptake inhibitors, while atomoxetine acts as a norepinephrine reuptake inhibitor. Guanfacine binds to post-synaptic alpha-2a adrenergic receptors. You use Table 2 to illustrate your explanations and to check the dose-adjustment strategies.2,5
Bio-equivalent does not mean clinically equivalent, especially when the release mechanism differs. For a generic drug to be declared bio-equivalent, the total quantity and maximum drug concentration (Cmax) of the active chemical must fall within a confidence interval of 80% to 125% in relation to the original product. The time to reach maximum drug concentration (Tmax) may differ and may increase the side effects, in addition to hindering the start and duration of action.
N.B.: Given that generic drugs have not been tested on clinical populations, their monographs contain information about the original product and the results of pharmacokinetic studies with small groups of healthy volunteers.
Research has shown that other agents such as bupropion and modafinil may be relatively effective in reducing ADHD symptoms. They are sometimes used as off-label drugs after the failure of conventional treatments.
Each patient’s clinical response is different. It is not possible to predict which medication will be most effective by symptom type or severity.
* The dose is from 3 mg to 6 mg, taken one or two hours before bedtime. Melatonin is available in the form of tablets and sublingual melts and as a liquid. In cases when melatonin supplementation has a direct hypnotic effect, sleep facilitation can be observed if taken 30 minutes before bedtime.
Canadian experts report that all ADHD drugs vary by type of active ingredient and release mode. Clinical symptoms (inattention or hyperactivity-impulsivity) do not allow us to predict which type of treatment will be the most effective. In addition, some people respond better to one product than to another, even within the same category of stimulants (preferential response). It is important to know that there is no relationship between dose, body weight and symptom severity when adjusting the dose of a psychostimulant.
In choosing among the available pharmacological options, clinicians must take into account several factors and points (Table 3).2 Table 42 reviews the general principles to reduce adverse effects, while Table 52,9 summarizes the points to consider in the presence of co-occurring disorders.
Nathan’s parents thank you for your explanations. You give them an infosheet on ADHD drug treatment (Toolbox Icon I) and on the management of side effects (Toolbox Icon 2), along with the CADDRA Patient ADHD Medication Form in the CADDRA Toolkit. You then schedule another appointment. You plan to provide more intensive follow-up during the drug adjustment period (from one to three months), then every six to twelve months when the patient’s condition has stabilized, taking into account developmental stages (more intensive for children and during transition periods). For school-aged children, it is best to meet with them after the first school semester (November) and before the last semester (April).
To measure both the positive and negative effects of the treatment, you suggest that they complete some clinical checklists and a drug therapy follow-up questionnaire (see the tools suggested in the article “In-Office Assessment of ADHD: Step-by-Step Approach” in this special edition).
Treatment for ADHD may include medication in the form of methylphenidate-based or amphetamine-based psychostimulants and non-stimulants.
In the event of an unsatisfactory response to treatment, you must review the diagnosis, ensure treatment compliance, make sure that no new factors have emerged to complicate the clinical presentation, and then consider switching to another drug.
You follow up Nathan’s family on a regular basis. The son and father are doing better after a few pharmacological adjustments and the gradual introduction of winning strategies (see the articles “ADHD: Tips and Tricks for Young People” and “ADHD: Tips and Tricks for Adults” in this special edition). The family thanks you for all the help you have given them. It warms your heart to see the progress both have made. //
French Version: Received: January 27, 2013 Accepted: April 11, 2013
Translated in English: September, 2014
Dr. Annick Vincent is a speaker and advisory committee member for Biovail, Lundbeck, Bristol Myers Squibb, Lilly, Purdue, Janssen and Shire. She received grants from Purdue, Shire and Janssen from 2011 to 2013. Dr. Michel Sirois was a speaker for Janssen Pharmaceuticals in 2012–2013 and an advisory committee member for Shire and Janssen Pharmaceuticals in 2012.