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There are now about 25 medicines for Attention Deficit Hyperactivity
Disorder (ADHD). The goal of this article is to make sense of this
potentially confusing group of choices. Medicine names are in bold below.
Key concepts are in bold or underlined and are summed up at the end.
Choosing a medication for ADHD is done after becoming reasonably
certain of the diagnosis and considering which, if any, treatment options,
are best for your child or you. Please see my detailed information packet
about ADHD at www.leeheymd.com.
It is also important to be clear what symptoms you want the ADHD medicine
to help, what possible side effects you especially want to avoid, and if
there are any convenience factors to consider. You and/or the youth must
also remember and accept that no medicine can do assignments, turn them
in, or make good choices. These medicines can only assist one's efforts -
moderately, to sometimes greatly.
ADHD medicines, especially the stimulants (see Medications
For ADHD) and the new non-stimulant Strattera, are most helpful
for distractibility (short attention span, poor ability to concentrate,
and lack of focus) and for hyperactivity (can't sit still, restless,
fidgety, excessive talking). Persons who have only the Inattentive
(distractible) type of ADHD without any hyperactivity also respond well to
stimulants and Strattera. Stimulants and Strattera are partially helpful
for the common impulse control problems of acting or speaking without
thinking first, blurting out, and butting into conversations, lines,
games, etc. No ADHD medicines directly help organization problems or
correct learning disorders like the various forms of reading and writing
(dyslexia), math, or processing disorders. However, by helping any
associated distractibility or hyperactivity, stimulants and Strattera can
have partial to sometimes substantial indirect benefits for learning
disorders and organization.
Since stimulants (also known as psychostimulants) and Strattera are
usually the best medicines for ADHD let's next simplify them. Actually
there are only 2 stimulant groups to consider. These are several forms of
methylphenidate and the amphetamines. (The most effective non-stimulant
medicine for distractibility is Strattera and will be discussed after the
stimulants.)So, really, this part is pretty simple. As you read on, be
aware the ER, SR, CD, LA and XR suffixes all mean extended, slow, or
longer duration forms of the basic medicine. Brand names are capitalized
below while the generic chemical name is not.
Methylphenidate (MPH for short) is the generic or chemical name
of the medicine known by the brand names Ritalin, Ritalin SR, Methylin,
Methylin ER, Metadate ER, Metadate CD, Ritalin LA, and Concerta ER. Thus,
these names all refer to the same basic ingredient. The main difference is
how long they last and what mechanism is used to make it last longer.
Methylin forms contain no dyes. As usual, generic forms, when available,
are cheaper. Focalin (dexmethylphenidate)is the single isomer form
of MPH which gives somewhat better duration and less rebound than MPH.
The amphetamines include Dexedrine (dextroamphetamine),
Dexedrine spansules (SR), Adderall, and Adderall XR. Adderall contains 50%
dextro-amphetamine and 50% of the very closely related isomer levo-amphetamine.
The addition of levo-ampetamine gives Adderall its better duration. Plain
Adderall comes in a generic but Adderall XR does not.
Let's next discuss the relative merits and demerits of the MPH and
amphetamine groups. MPH (methylphenidate) is the gold standard that
everything else is compared to; it's been around the longest and studied
by far the most. MPH is the mildest and it is cheap. It is a good place to
start. Amphetamines are stronger, generally last a bit longer, can have
more of a rough edge, and are more abusable. Some people do better on MPH
products and some do better on the amphetamine options - there is no
reliable way to tell which is better for you or your child without trying
them.
Let's talk duration. Plain MPH (Ritalin, Methylin) lasts 3 to 4
hours, Focalin lasts 4 to 5 hours, Dexedrine lasts a good 4 hours, and
plain Adderall 5 to 6 hours. Each requires at least 2 doses to cover
school hours while MPH and Dexedrine often require a third dose around 3
or 4 pm to also cover homework or work. Three doses a day (even two doses)
can be an inconvenient pain leading to missed doses or lack of
confidentiality due to having to take it at lunch at school or at day care
after school, etc. Except for Strattera, the big growth of new ADHD
medicine options is in ways to extend the duration of existing medicines,
not in creating new medicines to treat ADHD. Longer duration stimulant
options are not only more convenient, they are also often smoother (less
side effects and more consistent benefit through the day) and generally
don't cause the sometimes unpleasant "rebound" as the medicine
"wears off". There are 3 basic ways companies have developed
to increase the number of effective hours. First (and the oldest way),
is to make a hard coated pill that dissolves slower - Ritalin SR and the
generic MPH SR were made this way. In 2000 two companies came out with
minor modifications of this MPH form and a new 10 mg size (as well as the
generically priced 20 mg) - Methylin ER and Metadate ER.
These last 6 to 8 hours usually. A second method to extend duration was
brought out later in 2000 as Concerta, which uses a 3 layer osmotic
pressure release system to make plain MPH last 8 to 13 hours, usually 10
hours. In 2001 Metadate CD and Ritalin LA arrived as MPH
based capsules containing pellets of 2 different release time targets
which lasts about 8 hours. This capsule design containing time release
pellets is the third method for making stimulants last longer. Dexedrine
(SR) "spansule" capsules were the first of this capsule
strategy and typically last 6 to 8 hours. In late 2001 Adderall XR
became available in its 2 pellet typecapsule system to last 8 to 10 hours
thereby avoiding need for a midday dose at school or work. Concerta
(with MPH) and Adderall XR (with amphetamine) are the 2 longest duration
stimulant options. They may cover the whole day with only one morning
dose. Concerta, Adderall XR, Metadate CD, Ritalin LA, and Strattera
are brands costing over $2 a day and may be a high co-pay choice or are
not covered on some insurance formularies. Some patients will still
require a dose of regular MPH or amphetamine around 4 PM to cover the rest
of the day. Cylert (pemoline) is an effective, truly once a day non
abusable stimulant option that is little used since it has about a 1 in
10,000 risk of unpredictable severe liver damage or failure.
Page 2 of my
ADHD Medication chart shows non stimulant medicines that may help
ADHD. I'll start a new paragraph for the newest option:
Strattera (atomoxetine) is the new non stimulant FDA approved
(early 2003) ADHD medicine that rivals the stimulants in helping
distractibility (attention, concentration, focus) and perhaps
hyperactivity and impulsivity. It works via norepinephrine reuptake
inhibition (NRI) to increase primarily norepinephrine in the brain but has
little effect on dopamine. Stimulants increase both these
neurotransmitters but in a different way. Thus, Strattera helps ADHD while
often causing less appetite suppression, sleep disturbance, rebound,
irritability, tics, or other stimulant side effects. Strattera is not
abusable. As a convenience plus, Strattera can be called in and refills
can be written - no need for monthly handwritten prescriptions. Strattera
works to increase norepinephrine (NRI) in a way similar to how the
antidepressants Prozac, Zoloft, Paxil, Luvox, Celexa, and Lexapro increase
serotonin (SRI). Strattera may have some antidepressant benefit for some
people. Strattera must be taken 7 days a week to give a smooth and
effective level in the body and must build up for 2 to 4 weeks before it
is fully effective. In contrast, stimulants can be given when needed and
work for a certain number of hours and then are gone. The potential
advantage to the steady blood level effect of Strattera is that it should
be present and working 24 hours a day - even on awakening before the
morning dose is taken and late into the evening when stimulants have
usually worn off. Because of this slow build up effect it may be better
when changing from a stimulant to Strattera to overlap both meds the first
2 to 3 weeks. For some patients it may be helpful to take a stimulant or
other non stimulant medicine and Strattera at the same time on an ongoing
basis. In addition to a usually milder and less frequent group of possible
stimulant like side effects, Strattera may bother the stomach, cause
nausea, or cause sleepiness. Taking it with food, switching the medicine
to evening, or giving half in the am and half in the pm maywork better.
Strattera comes in capsules of several strengths, is usually started in
the morning, and the dosage increases with body weight. Response seems
better if the dose is set at the higher end of the recommended range and a
month should be given to gauge response.
Other options on page 2 of my ADHD medication chart are less helpful
for attention, concentration, focus, and distractibility than Strattera
and the stimulants but may have other advantages. These medicines include
the antidepressants Wellbutrin (buproprion) and imipramine (as well as its
cousins). Generally, if I am trying to mainly treat ADHD, especially
distractibility and inattention, I will use a stimulant or Strattera first
for that and add an antidepressant or anti anxiety medicine if depression
or anxiety are also present. Tenex (guanfacine) or clonidine
are not as helpful for distractibility and inattention as the stimulants
are but are just as good or better for hyperactivity and impulsivity. They
also don't cut appetite and tend to suppress tics. They are given 2 or 3
times a day. With Tenex lunch dosing can often be avoided. Amantadine
is a generic (Symmetrel is the brand name) that increases primarily
dopamine and not norepinephrine. Thus some patients respond better to its
similar but more limited actions. Amantadine is mainly used to treat
parkinsonism of various types and also prevents and treats Influenza type
A (not B). Amantadine comes as a capsule or liquid without much dose
adjusting possible except via the lliquid and is usually given twice a day
for ADHD. Provigil (modafinil) was approved by the FDA in 2000 for
"excessive daytime sleepiness" caused by certain sleep disorders
like sleep apnea and narcolepsy. Neither it or amantadine are approved by
the FDA for ADHD although doctors may use them for ADHD. There are only a
few studies so far showing amantadine or Provigil helps ADHD. Provigil is
only available as an expensive brand and is not yet on many insurance
lists. It comes as a tablet given once a day in the morning. Although it
is similar to other stimulants in several ways it also has differences
that make it an alternative when other stimulants fail or aren't
tolerated. All stimulants except Cylert and the non-stimulants amantadine,
Provgil and Strattera may be abused which gives another reason to consider
these options in certain situations.
To summarize, despite the growing number of medicines for ADHD,
stimulants remain generally the first choice. Strattera is a new,
potentially effective, non-stimulant attention span boosting option.
Almost all the other "new" medicines are just extended duration,
brand name (costlier) versions of the big two: methylphenidate (Ritalin)
and amphetamine (Adderall). These new options do often, but not always,
bring benefits that outweigh their extra monetary cost. There remain a few
non stimulant older options and a few atypical stimulant choices to
consider mainly as back-up plans.
Medicines For ADHD