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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
http://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 usually, sometimes greatly.
ADHD medicines,
especially the stimulants (see Medications
For ADHD) and the 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, and impulsive
temper. No ADHD medicines directly help organization problems (which
are also known as Executive Functioning Disorder) 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 of the amphetamines. (The most effective non-stimulant medicine for
distractibility is Strattera and will be discussed after the stimulants.)
So, really, this part is simpler than it looks. 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.
Usually side
effects can be avoided by conservative dosing and by fine tuning dose
and form via close monitoring. Potential side effects include appetite
decrease as #1. If the dose
is too strong or medicine is wrong speedy effects like delayed sleep
onset, headache, stomach ache, tense muscles, dry mouth or irritability
may occur. Or the person may
feel too subdued, too calm, loose their spunkiness, or seem
"zombie" -like. Tics
may occur especially in persons with a tendency toward them.
Blood pressure or heart rate increases are possible though rarely
significantly. All these are
reversible by decreasing, changing, or stopping the medicine.
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, Concerta
ER and Daytrana (a skin patch form of MPH). 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. Generic forms, when
available, are cheaper. Focalin (dexmethylphenidate) is the single
isomer form of MPH which may give better duration and less
"rebound" than MPH.
The amphetamines
include Dexedrine (dextroamphetamine), Dexedrine spansules (SR), Adderall
(generic known as "mixed amphetamine salts"), Adderall XR, and
(the newest) Vyvanse (lisdexamfetamine).
Adderall contains 50% dextro-amphetamine and 50% of the very
closely related isomer levo-amphetamine. The addition of levo-ampetamine
gives Adderall its longer 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 studied
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
a hassle 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 are less likely to cause the
sometimes unpleasant "rebound" as the medicine "wears
off". There are now 5 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 OROS
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. Adderall XR does the same with
amphetamine and lasts closer to 10 hours.
This capsule design containing time release pellets is the third
method for making stimulants last longer.
The fourth method came out in 2006 as the Daytrana
transdermal system. This is a
skin patch designed to be placed daily on one hip early each
morning and removed about 9 hours later.
The patch can thus avoid an oral dose. The fifth method appeared in
2007 as Vyvanse which is Dexedrine (dextroamphetamine) bonded to
the amino acid lysine which results in a duration of 10 to 12 hours. This
"pro-drug" (meaning pre or before) is not active until enzymes
in the gastrointestinal tract or liver cut the lysine bond to free up the
dextroamphetamine. This takes
time and both results in extra duration of action and makes
'snorting" or injecting it not worthwhile, thereby reducing abuse
potential. The Daytrana skin
patch (and less so Concerta) also reduce abusability.
Dexedrine (SR)
"spansule" capsules were the first of the capsule strategy and
typically last 6 to 8 hours. In late 2001 Adderall XR became available in
its 2 pellet type capsule system to last 8 to 10 hours thereby avoiding
need for a mid day dose at school or work. Concerta or Daytrana skin
patch (with MPH) and Adderall XR or Vyvanse (with amphetamine) are the
longest duration stimulant options. They may cover the whole day with only
one morning dose. Focalin XR is next longest.
Concerta, Adderall XR, Vyvanse, Metadate CD, Ritalin LA, Strattera,
Focalin XR, and Daytrana are brands costing over $3 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.
Preparation
types available thus include tablets both short and longer
duration (MPH, Focalin, Adderall, Methylin ER, Metadate ER, Ritalin SR,
MPH SR), capsules that release 50% quickly and 50% in about 4 hours (Focalin
XR, Ritalin LA, Dexedine Spansues, Adderall XR - all of which can be
sprinkled on food to ease swallowing; Metadate CD does the same except it
releases 30% immediately and 70 % later), the Concerta 3 layer techno
pill, capsules not designed for splitting (Vyvanse and Stratera), and the
Daytrana skin patch. Methylin
also makes a liquid dose form that lasts up to 4 hours for
situations where a liquid is preferred. All Methylin forms contain no
dyes.
Page
2 of my ADHD Medication chart shows non stimulant medicines that
may help ADHD. Strattera
(atomoxetine) is the non stimulant FDA approved (early 2003) ADHD medicine
that may rival the stimulants for at least some persons 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 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 rarely have some antidepressant or anxiety benefit. 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 few 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 by causing nausea, or cause
sleepiness. Taking it with food, switching the medicine to evening, or
giving half in the am and half in the pm may work better.
Strattera comes in capsules of several strengths, is usually
started in the morning, and the dosage increases with body weight.
Response mat be better if the dose is set at the higher end of the
recommended range although some people respond and tolerate it better at
low doses). Two to four weeks should be given to gauge response.
A recent study and clinical experience show that some people
respond better to Strattera than a stimulant or vice versa.
If one doesn't work well the other may still help.
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 possibly
Strattera first for that and then 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 do suppress tics (which
stimulants may precipitate or worsen). They are given 2 or 3 times a day.
With guanfacine 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 liquid and is usually given twice a day for ADHD.
(Two brand name and more pure dopamine agonists, Mirapex or Requip,
could also be tried.) 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 that amantadine or Provigil helps ADHD. Provigil is only
available as an expensive brand. 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 may be abused but
the non-stimulants amantadine, Provgil and Strattera are not abusable
which gives another reason to consider these options in certain
situations.